
Class RC 2-QI 

Book Ji^i_ 

Copyright^? 

COPYRIGHT DEPOSIT. 



1 



Iti 



it 






SYPHILIS IN ITS MEDICAL, MEDICO- 
LEGAL AND SOCIOLOGICAL ASPECTS 



SYPHILIS 

IN ITS MEDICAL, MEDICO-LEGAL 
AND SOCIOLOGICAL ASPECTS 



BY 

RAVOGLI, 



M.D. 



Professor of Dermatology and Sy philology in the Medical College of Ohio, Medical 
Department of Cincinnati University, Dermatologist to City Hospital 
of Cincinnati ; Member of the Ohio State Board of Medical 
Registration and Examination 




THE GRAFTON 

PUBLISHERS 



PRESS 



NEW YORK 






USflARY of CONCUSS 
Two Cooles Receiveo 

SEP 7 *90f 

Copyncht Entry 

CLASS>A XXc„ No. 

COPY B. 



Copyright, 1907, by 
THE GRAFTON PRESS 



To Dubois-Havenith 

to whom humanity must feel indebted for his 

courageous and persistent work for the public prophylaxis 

of syphilis and kindred diseases 

this Book 

is humbly dedicated 






PREFACE 

Contagious diseases, as a menace to the individual by their method 
of spreading, and as a menace to the race by their transmitted heredi- 
tary taint, offer an interesting field of study to the physician. The 
physician, more than anyone else, must try to prevent their spreading, 
and must enlighten the people concerning their existence and their 
consequences, so that the necessary precautions may be taken to 
protect society. Syphilis, as an infectious and contagious disease, 
which is communicated to the healthy by inoculation, and is trans- 
mitted by heredity to the fetus, either kills the fetus in utero, or causes 
the child to come into the world a tainted creature, demands our atten- 
tion as a subject for study of deepest interest. 

The connection between syphilis and social relations is so little 
understood that the name of the disease alone is sufficient to cast a 
mark of dishonor on the man who has had the misfortune to be 
inoculated. The public in general, ignorant of causation, is unable 
to understand the difference between one innocently infected and one 
who exposes himself to infection through lack of morality. Indeed, 
we shall never expect to be understood by superstitious people who, 
with religious devotion, carry about a potato in their hip pocket, which 
they believe will absorb all their rheumatic humors, or by those who 
carry pieces of carbon left by the arc lights for the same superstitious 
purpose. Neither do we expect to be understood by those who, on 
account of their belief in occult virtues, wear an iron ring on their 
little finger, which they claim to be electric and able to cure them of 
all their rheumatic pains which may be the result of a gouty condition, 
or perhaps of an old neglected syphilis. 

Whoever entertains such irrational views and such dispropor- 
tionate hopes, is superstitious and incapable of realizing that when 
a man has an eruption on his face, although it may be of a syphilitic 
nature, the fault of the infection does not necessarily rest on the lack 
of morality of the person. A great many, ignorant of the manifesta- 
tions of any disease of the skin, are likely to think any eruption on 
the face or on the hands the result of syphilis. 

It is for this reason we have decided to publish a few sociological 
considerations on this dreadful disease, for the purpose of placing the 
man who is infected with syphilis in a true social light. In many 



viii PREFACE 

cases the fault is with the man infected, who in a moment of forget- 
fulness, misled by his companions, may have been indiscreet, although 
his moral character is good and irreproachable. For a young man 
of this kind, contracting this disease is a lesson in life which will 
remain vivid in his memory. The fear of the disease and of its con- 
sequences makes him take care of himself, stop the use of alcoholic 
beverages, stop smoking; reforming him entirely. 

We also find a large number of patients who have been acci- 
dentally infected with syphilis, cases which have been called syphilis 
insontium, where the disease has been contracted accidentally, or in 
the discharge of professional duties, as among physicians, dentists 
and midwives. In these cases the man or woman was infected, while 
he or she did not deserve such punishment, and syphilis must then be 
considered as a non-venereal disease. 

Syphilis, through the lymph and blood vessels reaches any organ 
and any tissue of the human body, and remaining in the system, is 
capable of bringing about so peculiar an appearance of the features 
of the individual that it is easily discovered by the eye of a skillful 
physician. This was pointed out by Ferdinand Hebra as ein ganz 
speciiisches Gesicht. If this is true of the general appearance of the 
body and especially of the face, it must also be so of the general 
mental condition of the person affected, for syphilis does not spare 
the delicate structure of the nerve cells, especially those forming the 
gray matter of the brain, and we quite often see specific affections of 
the nervous system in all the periods of the evolution of syphilis. 
Just as syphilitic eruption leaves marks on the skin, any attack on 
the nervous system must leave traces which late in life will become 
more pronounced. Indeed, if a syphilitic child shows unmistakable 
signs of syphilis in his or her bones in a form of dactylitis, he or she 
must also show signs of affection of the nervous system, which may 
be revealed in its motor or psychical functions. It is not difficult to 
perceive anomalies in the motor function, but the psychical condition 
is frequently hidden and only those who are constantly in contact with 
such a person are able to perceive the alterations of the psychical 
sphere. 

It is, therefore, easily understood that all these questions per- 
taining to the syphilitic alterations in the man who becomes infected, 
and to all his relations to his wife, to his family and to society, form 
a vast and important sociological study, which we shall carefully con- 
sider in all its details. 



CONTENTS 

PART I ■ 

THE MEDICAL ASPECTS 

THE TRANSMISSION OF SYPHILIS 

CHAPTER PAGE 

I. Historical Sketch of the Search for the Causal 

Agent 3 

II. Pathological Process of Infection 14 

III. Modes of Infection 22 

THE EVOLUTION OF SYPHILIS 

IV. Primary Syphilis 28 

V. Constitutional Syphilis 38 

Affections of the skin 41 

The skin appendages 52 

Late syphilis of the skin 54 

Other tissues and organs 56 

Oro-pharyngeal cavity 60 

Alimentary tract 65 

The respiratory tract 6j 

The heart and blood vessels J2 

The liver, spleen and kidneys 79 

The male genito-urinary organs 84 

The female genito-urinary organs 89 

The bones and joints 90 

The muscles and bursas 101 

VI. Syphilis of the Nervous System 105 

The brain 105 

The spinal cord 112 

General syphilitic affections of the nervous system 116 
ix 



x CONTENTS 

CHAPTER PAGE 

Locomotor ataxia 121 

General paralysis 123 

Syphilis of the organs of the special senses . . 127 
VII. The Nature of Syphilis as Influenced by Other 

Conditions 136 

Causes of malignancy 136 

Mixed infection 138 

Tuberculosis 140 

Alcohol 140 

Tobacco 141 

Other disease causes 142 

Individual dangers from syphilis 143 

VIII. Parasyphilitic Affections 152 

IX. Influence of Syphilis Upon Other Diseases . . . 158 

X. The Treatment of Syphilis 171 

External treatment 177 

Internal treatment .183 

Injection treatment 189 

Inunctions 195 

Fumigation 202 

Physiological action of mercury 205 

Mercurial poisoning 211 

Thermo-mineral baths 212 

Iodides 213 

Individual prophylaxis 223 

XL The Transmission of Syphilis to the Offspring . 229 

Direct transmission 229 

By conception 235 

Germinative infection 238 

Congenital and hereditary syphilis 240 

Maternal heredity 245 

Maternal heredity alone 250 

Sterility from syphilis 251 

Syphilitic immunity 254 

Symptoms and consequences of congenital and 

hereditary syphilis 264 

General treatment of congenital syphilis . . .271 

Constitutional treatment of congenital syphilis . . 273 

Prophylaxis 275 

Retarded hereditary syphilis 284 

Latency of inherited syphilis 293 

Syphilis of the third generation 299 



CONTENTS xi 

PART II 

THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

CHAPTER PAGE 

I. Syphilis and Marriage 317 

Syphilis as an impediment to marriage . . . . 317 

Syphilis as cause of divorce 321 

Damages in cases of syphilis 324 

The medical secret 329 

Professional ethics and syphilitic patients . . . 336 

In reference to marriage and to family .... 338 

II. Syphilis in Relation to Degeneracy 343 

Degeneracy 352 

Physical signs of degeneracy . . . -. . . 366 

Syphilis and the decadence of populations . . . 370 

Syphilis as a predisposing cause of crime . . . 392 

Syphilis and sexual perversion 405 

III. Syphilis and the Public Health . . . .. . . 412 

Syphilis and life insurance 425 

Public prophylaxis in regard to prostitution . . 439 

Prostitution of minors 448 

Causes of prostitution 452 

Proxenetism and procuresses . . . . . . 456 

Sanitary consequences 459 

Prevention and coercion . . . . . . . . 463 

Juvenile courts 465 

Industrial schools 473 

IV. The Regulation of Prostitution in the Public 

Prophylaxis of Syphilis 480 



ILLUSTRATIONS 

PLATE F CING PAGE 

I Trypanosoma lues . . . . . . .12 

II Syphilitic roseola. — Roseola annularis . . . .42 

III Large papular syphilide, hypertropic type. — Papulosqua- 

mous syphilide four years after infection . . 46 

IV Circinate syphilide of diffused type .... 48 
V Pigmentation left by hemorrhagic papular syphilide . 50 

VI Syphilis ulcerosa . . . . . . 52 

VII Papular syphilide with gangrenous spots . . .56 

VIII Phagadenic syphilitic ulcer with elephantiasis of the anus 

and vulva ........ 60 

IX Large papular syphilide. — Circinate papular syphilide . 64 
X Syphilitic cutaneous gummata, ulcerated. (Syphilis 
tuberculo-ulcerosa). — Ulcerated gumma of the nose. 
— Destruction of the septum nasi and portion of 
superior lip from syphilitic gumma . . .68 

XI Ulcus perforans. — Multiple ulcerated gummata . . 72 

XII Twin boys from syphilitic parents, one infected and the 

other healthy ....... 250 

XIII Examples of Congenital Syphilis : 

Large papular eruption. — Rupioid form ; child died of 
pneumonia. — Diatrophy of right hand and left arm; 
child died of eclampsia . . . . . 268 

XIV Diatrophy of the fingers in a heredo-syphilide. — Ulcerated 

gummata in a heredo-syphilide .... 306 

XV Leon F. Czolgosz. — Stigmata of degeneracy in a criminal 402 

XVI Francesco Gioli ........ 406 



Xlll 



PART I 
THE MEDICAL ASPECTS 



PART I 
THE MEDICAL ASPECTS 



THE TRANSMISSION OF SYPHILIS 



I 

HISTORICAL SKETCH OF THE SEARCH FOR THE 
CAUSAL AGENT 

It is indeed astonishing to find authors who have denied the 
existence of the syphilitic virus, and others, like Brussais in France 
and Huber in Germany, who have even denied the existence of syphilis. 
There is no one to-day who could for a moment have a doubt con- 
cerning the contagiosity of syphilis and the inoculation of a healthy 
person by an infected one. 

Although until lately science had not positively discovered the 
exact nature of the syphilitic virus, yet by its contagiosity, course, 
and symptoms, it was always believed to be due to a living germ. 
Many investigators had searched in the blood and in the secretions 
of syphilitic patients, they had often referred to the discovery of a 
peculiar living organism, but later on it had been found to be not at 
all characteristic of the syphilitic affections. 

All the observations of this kind made before the founding of 
the science of modern bacteriology have remained as mere historical 
curiosities without scientific importance. To this category has to be 
referred the vibriolineola of Mueller and Donne, the micrococci of 
Hallier, Klotzsch, Salisbury and Bruhlkens, and the peculiar bodies 
of Losdorfer, which he claimed to have found in the blood of syphilitic 
persons. Observations afterwards made in the light of modern bac- 
teriology also remained unsuccessful. It would take a long time to 
mention everyone who has believed that he has seen the syphilitic 
germ, and has tried to demonstrate its existence, from Klebs, 1879, 
to Petrone, Barduzzi and Marcus, 1884. Their results were unsatis- 
factory and contradictory; no one has succeeded in showing a con- 
stant form of micro-organism in the inflammatory productions or in 
the blood of syphilitic persons, neither have they succeeded in a 



4 THE MEDICAL ASPECTS 

positive inoculation of a culture in the lower animals. It was about 
the end of the same year, 1884, that Lustgarten x in a preliminary 
communication announced that he had detected a special bacillus in 
the syphilitic tissues by means of a peculiar method of staining. In 
the following year 2 he gave a more detailed description of this 
bacillus ,and of the staining method. Doutrelepont 3 and Schiitz fol- 
lowed in claiming the discovery of the bacillus of syphilis by a method 
of staining nearly identical to that of Lustgarten, and De Giacomi, 
Gottstein and Baumgarten stated that they had succeeded in finding 
bacilli in an initial lesion. 

Lustgarten examined sixteen cases of different lesions, such as 
indurated chancres, mucous patches and gummata. The bacilli were 
found in very small numbers, and attempts at cultivation were not 
successful, while the last mentioned authors with the decolorizing 
method succeeded in detecting bacilli in an initial lesion, which with 
the Lustgarten method could not be found. 

At this point Cornil 4 communicated to the Academy of Medicine 
of Paris that Alvares and Tauel had found in the smegma taken from 
a healthy person, bacilli, which reacted in the same manner with 
aniline dyes as the bacilli described by Lustgarten. Furthermore, the 
above named authors did not find the Lustgarten bacillus in scleroses 
and mucous patches of the mouth, and of a gumma of the lungs, but 
they found the organisms in the secretions of chancres, gummata, 
mucous patches, as well as in three cases of soft chancre, in the fluid 
of vesicles of herpes preputialis and in pemphigus vulgaris on the 
genitals of both sexes. In the smegma taken from the prepuce, from 
the large and small lips of the vulva, and from the region of the anus, 
the same bacilli were found which gave a similar reaction to those 
described by Lustgarten. 

The same results were obtained by Klemperer, who at a meeting 
of the Berlin Medical Society confirmed the observations of Alvares 
and Tauel, giving in this way a blow to the specificity of these bacilli. 

It would be a long and difficult task to mention all the observers 
and authors who have worked in this direction, men of great scientific 
ability, such as Dutrelepont, Matterstock and Bitter. Disse and 
Taguchi, Lingard and Eve, Andromico, Habercorn, Marcus, Man- 
surow, Leloir, Babes, Koeniger and Fordyce, 5 all believed they had 

1 Wiener Med. Wochensch. 1884. 

2 Wiener Med. Jahrbucher. 1885. 

3 Doutrelepont. " Bacillen bei Syphilis," Deutsche Med. Wochensch. No. 19. 
1885. 

4 Cornil. Gazette des Hopitaux, No. 90, 1885. 

5 John A. Fordyce. " A System of Genito-Urinary," etc., edited by Prince 
A. Morrow, p. 47. 



SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 5 

succeeded in finding a peculiar bacillus in a few cases of syphilitic 
scleroses or in the tissues of the mucous patches. 

Lately Jullien communicated to the Academy of Medicine of Paris 
the results of his investigations made with the co-operation of Dr. 
Delisle in the Pasteur Institute. He demonstrated the presence of an 
aneroid bacillus in the blood of syphilitic patients. He was able to 
cultivate the bacillus in blood serum, and to inoculate different lower 
animals, finding that frogs and pigs showed great sensitiveness to this 
poison. 

Max Yon Niessen 6 had also described a bacillus which he claimed 
to have found in the blood of syphilitic persons, which grows on 
nutrose agar, the color of which changes into yellow and yellowish 
green. It is colored by the staining method of Gram Nicolle. He 
claims to have found the same bacillus in all stages of syphilis. He 
inoculated monkeys and pigs with the cultures of this bacillus. The 
monkeys soon died after the inoculation, some showing diffuse erythema 
and inflammation of the lymphatic glands. In one monkey which 
remained alive for some time, a form of hepatitis developed with 
hypertrophy of the capsule of the liver and under the microscope the 
blood-vessels showed the same appearance as in man. Another monkey 
after a certain time was affected with epileptiform attacks. He spoke 
of papular eruptions, sclerosis, gummata and also of periostitis de- 
veloped in the pigs. Although the observations were of great interest, 
and the article was beautifully written, yet it was severely criticised 
by Ludwig Walsch of Prague in the Archiv fur Dermatologie und 
Syphilis, July, 1901. Walsch showed a lack of proof in Von Niessen's 
findings, premature conclusions from the results of his inoculations, 
and inconsistency of his projected therapeutics. 

Max Joseph 7 made a communication to the Berliner Medisin- 
ischen Gesellschaft, with illustrations, showing some peculiar bacilli 
found in the sperma of syphilitic patients at the height of the infectious 
period. The work was done in Dr. Piorkowski's Bacteriological 
Institute in Berlin, and was followed by another lengthy communica- 
tion by Dr. Joseph at the meeting of the Deutscher Natur-f or sellers 
und Aerzte in Karlsbad, September 24, 1902. 

Joseph started with the idea that a man who has been infected with 
syphilis, after two or three years, while apparently well, having sexual 
intercourse with a healthy woman, does not communicate the disease 
to her. But when the woman is fecundated, then the fetus is infected 
and communicates the disease to the mother. As a consequence he 

6 Von Niessen. " Beitrage zur Syphilis Forschung," Wiesbaden. 1901. 
'Joseph, Max. Berliner Klinische Wochenschrift. No. 13 and 14. 1902. 



6 THE MEDICAL ASPECTS 

concluded that the syphilitic virus remains longer in the semen than 
in other secretions of the organism. He used sperma of syphilitic 
persons for inoculations, and as a culture medium pieces of sterilized 
placenta, which were inoculated mostly on the maternal side, and were 
kept in an incubator at the temperature of 37 C°. After twenty-four 
to forty-eight hours he could see on the inoculated places small points, 
grayish in color, which were colonies of micro-organisms which he 
recognized as bacilli. He compared these bacilli with those of diph- 
theria, and they were easily stained with carbolfucsin and gentian 
violet. He claimed to have found these bacilli in many cases of 
syphilitic persons five years after infection, although they had under- 
gone several treatments. He found the same bacilli in the tissues of 
the hard chancre, but he never could find them in the chancroid, or 
in simple erosions of the genitals. The bacilli were also present in 
ulcerated mucous patches of the scrotum, of the vulva and of the 
mouth. He claimed to have obtained positive results from the inocula- 
tion of pieces of inguinal glands, which had been removed from the 
groins of syphilitic patients under the strictest asepsis. 

Joseph bases the specificity of these bacilli on their peculiar shape, 
and on their peculiarity of vegetating only on the placenta as a 
culture medium. The cultures of these bacilli were inoculated on 
rabbits and guinea pigs without any results, but it seems that in a 
pig, several days after inoculation, an erythematous eruption appeared 
around the genitals, with ulcerations. The pig died and the lymphatic 
glands were found greatly hardened and swollen. But on the other 
hand another pig inoculated with different cultures proceeding from 
syphilitic tissues did not show after several months any perceptible 
alterations. 

He showed many preparations of the bacilli and explained the 
method of staining, which is a combination of Ziehl-Neilsen's method. 
The specimens first imbedded in paraffin are cut in thin sections and 
are placed in xylol for twenty-four hours, then in seventy per cent, 
and in absolute alcohol. The section is placed on the glass slide and 
dried with blotting paper, and kept for four hours in a solution of 
diluted carbol-fuchsin, then it is placed in a mixture of water and 
alcohol with three per cent, nitric acid. It is dried again and stained 
with Loffier's methyl-blue solution for a few minutes, then washed, 
dried and mounted in Canada balsam. 

In the examination of the lymph glands he claims that the bacilli 
are very numerous in the middle, in the lymph spaces, and very few 
towards the periphery. 

This announcement of having found the so much searched for 
bacillus of syphilis caused the same objections among the scientists as 



SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 7 

in the ether cases. Delbanco 8 referred to the observations made by 
H. Pfeiffer in fifteen normal urethrae and in twelve affected with gonor- 
rhea, by means of preparations on the cover glass, and by means of 
culture. In these preparations he found a large number of bacteria 
belonging to the group of pseudo-diphtheritic bacilli. Not one of the 
men furnishing the material for examination was syphilitic. The mor- 
phological appearance of those bacilli was exactly the same as that of 
those described by Joseph and Piorkowski as syphilis bacilli, and yet 
they are only an innocent kind of parasite, which have been mixed 
with the sperma while passing through the urethra. The only part 
difficult to be explained was the presence of the bacilli in the swollen 
syphilitic glands, found by Max Joseph in two instances. 

Paulsen, 9 at the biological section of the Medical Association of 
Hamburg, had already demonstrated bacilli having a great resemblance 
to those of diphtheria in cultures of the blood taken from the forearm 
of a man covered with syphilitic roseola, and once from the lymph 
taken from the swollen lymphatic glands of the groins, while the 
initial chancre was still present. The bacilli, although showing great 
likeness to those of diphtheria, have many characteristics which differ- 
entiate them. Paulsen limited himself to announcing the fact without 
deducing any conclusion. 

In 1884 Loffler, while treating the subject of diphtheria in calves, 
referred to a bacillus which he had obtained by inoculating rabbits 
with products from syphilitic lesions. This bacillus is morphologically 
similar to that of diphtheria of calves. From his experiments he con- 
cluded that, on the raw surface of mucous patches, parasitic bacilli 
find a good ground for their development. 

When in September, 1902, at a meeting of the Carlsbad physicians, 
Joseph and Piorkowski read their second communication, " Weitere 
Beitrage zur Lehre von den Syphilis-bacillen," Walsch spoke of his 
observations of the presence of the v. Niessen bacillus. He found this 
bacillus in six instances in the blood of syphilitic persons during the 
secondary period and also a yellowish diplococcus, which he had found 
three times. He had obtained the same bacilli in the culture of the 
serum taken from the inguinal glands removed from syphilitic patients. 
The blood taken from healthy people, and from syphilitic persons in 
the tertiary stage remained negative. 

From the blood of patients affected with syphilitic roseola, which 
had been inoculated on organs taken from the pig, bacilli were ob- 
tained, which had been described by v. Niessen, and had afterwards 

8 Delbanco, Ernst. " Einige Notizen zu dem Aufsatz von H. Pfeiffer: 
Ueber Bakterienbefunde in der normalen mannlichen Urethra mid den Syphilis 
Bacillus von Max Joseph." Monatsh. fur Prakt. Dermatologie. 1903, No. 5. 

9 Paulsen. Munch. Med. Wochenschr. 1902, No. 9. 



8 THE MEDICAL ASPECTS 

been found by Adrian, Holzhauser and Hiigel. Walsch considered 
the bacilli found by himself, and those found by Joseph" and Piorkowski 
as pseudodiphtheritic bacilli, which so far do not throw any light on 
the obscure etiology of syphilis. 

Delbanco maintained the same opinion, and he believes that the 
bacilli alleged to be the cause of syphilis are only pseudodiphtheritic 
bacilli, which ought to be called bacilli found in syphilitic persons. 
We must not forget that in syphilis the initial lesion is usually ulcerated, 
the moist papules are ulcerated, and all are open doors for the entrance 
of secondary bacilli, which are taken in by the lymphatics and carried 
into the glands, and are also brought into circulation in the different 
parts of the system. The same order of secondary bacilli is found in 
lepra. The claim of Joseph and Piorkowski to have found the bacillus 
causa proxima of syphilis, falls to the ground and the bacilli that they 
have demonstrated are the very same found by Pfeiffer, Paulsen, 
Walsch ; only a kind of diphtheroid bacilli, which are found in syphilitic 
patients as secondary bacilli. 

Max Schiiller 10 described a peculiar form of round or oval bodies 
in the tissues of the syphilitic sclerosis, which he describes as forms 
of spores which appear closed in capsules. He finds that they are 
capable of some movements and compares them to a kind of sporozoa. 
In our pathological studies we have met with these peculiar forms, 
which are very visible when stained with Bismarck brown, made up 
of round bodies, which are nothing else than thrombi made up by an 
accumulation of leucocytes inside of the small lymphatics. We have 
already pointed out these conditions of the lymph-vessels in an article 
read to the meeting of the Fourteenth International Medical Congress 
in Madrid, 1903. We have found that the lymphatic vessels are 
affected by an inflammatory process, their endothelial cells are enlarged 
and in some places detached. The lymphatic vessels starting from 
the initial sclerosis are also enlarged and show irregular dilations 
during their course in the form of cul-de-sacs. They are filled with 
mononuclear leucocytes, which occlude the lymphatic vessels. The 
syphilitic virus seems to possess an agglutinating power on the serum 
and the leucocytes easily stick to the endothelial lining, so that the 
lymphatics are at times plugged up with lymphatic thrombi. We there- 
fore refer the peculiar appearance in the form of stars composed of 
round bodies, to a thrombosed condition of the lymphatic vessels, cut 
in transverse section. 

The question still remained sub judice. Everybody believed syphilis 
to be a disease of bacillary nature, and nobody doubted that the bacillus 

10 Schiiller, Max. " Mitteilung iiber die protozoenahnlichen Parasiten bei 
Syphilis." Dermat. Zeitschrift, 1903, Heft 4. 



SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 9 

would be found. One of the difficulties was that the syphilitic virus 
had not yet been successfully inoculated in animals, and in consequence 
was also refractory to inoculation on artificial culture media. In 
reference to the bacilli, which were claimed to be syphilis bacilli, and 
then shown to be smegma bacilli, Pizzini was of the opinion that they 
were probably tubercle bacilli, which if in a dormant state are easily 
aroused by the syphilitic virus. The morbid symptoms produced in 
animals by the inoculation of these cultures were in all probability 
only the result of acute tuberculosis. 

In these last years a new era in the study of syphilis has begun, 
which indeed promises to cut asunder the veil which has enveloped 
the cause of the disease. 

Metschnikoff and Roux 1X announced the discovery of the suc- 
cessful experimental transmission of syphilis in the monkey, and not 
much later the finding of the pathogenic agent in a form of spirillum 
by Schaudinn and Hoffmann was announced. Inoculation of syphilis 
in apes occurs in those of the anthropomorphous kind, as it was con- 
firmed by Lassar 12 in a chimpanzee in the Aquarium in Berlin, and 
later by Neisser. From the experiments it was found that the chim- 
panzee is susceptible to infection with syphilis just as man. Twenty- 
two animals were inoculated, all with positive results. In any place 
where the inoculation has been done a characteristic syphilitic initial 
lesion has developed. The regions more often inoculated have been the 
brow or the eye-lid, which are more easily watched. The initial lesion 
has appeared between fifteen and forty-nine days after the inoculation, 
giving an average of thirty days of incubation. The initial lesion is 
not different from that which is seen in man, being in form of a small, 
hardened papular knot, bluish red in color, which soon is excoriated 
and then ulcerated, and covered with crust. After one or two months 
the lesion heals, the hardness gradually disappears and only a super- 
ficial cicatrix remains, stained with a brownish pigmentation. The 
anatomo-pathologic alterations of the lesion in the monkey is just the 
same as in man, as was shown by Lassar, Arnal, Salmon, Thibierge 
and Ravau. These consist in an infiltration of small mononuclear 
leucocytes surrounding especially the blood and lymph vessels, and 
in some cases true peri- and endoangioitis. 

After the onset of the syphilitic initial lesion the lymph glands 
are hard and enlarged, at first near the lesion, soon after of the whole 
body. 

In sixty-six per cent, of the inoculated animals, in from twenty 

11 Metschnikoff and Roux. " Ueber die experimentelle Syphilis.'' Ref. 
Berlin Klin. Wochenschr. No. 52, 1903. 

12 Lassar, O. " Ueber Impfversuche mit Syphilis am anthropoiden Affen." 
Derm. Zcitschr. Bd. xi. 



10 THE MEDICAL ASPECTS 

to forty days from the first local lesion, general symptoms occur in the 
form of ulcerated papules of the genitals, of the chest, in the form of 
excoriated mucous patches of the mouth, papulo-squamous syphilides 
of the palms and soles. In the chimpanzee these symptoms, perfectly 
identical with those of man, are not so severe, are less extensive and of 
shorter duration. After three to four weeks they undergo an involutive 
process and disappear. In one instance only the eruption was of malig- 
nant form, of a rupioid nature, with extended ulcers ; the animal 
showed deep cachexia and soon after died. 

Visceral complications in the animals such as a hypertrophic con- 
dition of the spleen and nervous disturbances, and paresis of the 
posterior limbs, with abolition of the knee jerk were found. 

So far, no symptoms of late syphilis have been observed in the 
inoculated animals, because not one has lived more than thirteen 
months after the infection. Death has been caused in nearly all cases 
by infectious broncho-pneumonia. 

Experiments were repeated in other kinds of apes, as in the gorilla 
and ourang-outang, but after the appearance of the initial lesion no 
general symptoms have followed. In the same way experimental 
inoculations were made in the macachous rhesus, speciosus, cynomol- 
gus, cynocephalus, cercopithechus, fuliginous and ruber, in many dif- 
ferent countries, with the same results. In every case the initial lesion 
has appeared, but no general cutaneous manifestations have followed. 
The glands surrounding the initial lesion have become enlarged, show- 
ing that the virus does not find an appropriate soil and soon is attenu- 
ated and dies. 

We owe to the experimental researches of Neisser the confirmation 
of the knowledge already acquired from clinical observations, that the 
initial lesion and the mucous patches, as well as the cutaneous papules, 
are capable of transmitting the disease. He proved, furthermore, that 
the lymph glands and the serum from a bulla of syphilitic pemphigus in 
an infant with congenital syphilis could inoculate the disease. 

It seemed that other organs, spleen, liver, marrow of bone, cere- 
brospinal fluid, had given negative results, but in successive inocula- 
tions in Batavia, Neisser succeeded in inoculating apes with these 
organs taken from other syphilitics. 

In April, 1905, Schaudinn (unfortunately so soon lost to science 
and to humanity), then director of the laboratory for the study of the 
protozoa in the Berlin Institution, together with Hoffmann, lecturer 
on syphilology, announced the discovery of a micro-organism in the 
syphilitic products, which had never been described, belonging to the 
spirilla variety, difficult to stain, and from this peculiarity of taking 
little of the stain when treated with Giemsa's azur and eosin. they 



SKETCH OF THE SEARCH FOR THE CAUSAL AGENT n 

called it spirochaeta pallida. Schaudinn and Hoffmann in their first 
note expressed themselves guardedly in reference to the significance of 
their discovery, but in their second publication insisted on the duality 
of the spirochaeta^, the spirochaeta refringens and spirochaeta pallida, 
the former of a relatively large size, wave shaped, easily stained, the 
second, found only in syphilitic products, much smaller in size, cork- 
screw shaped and only stained by special stains. 

Although the discovery was at first accepted with a great deal of 
skepticism, within a few weeks after this announcement many re- 
searchers confirmed the fact brought out by the two discoverers. 
Metschnikoff and Roux read a communication to the Paris Academy 
of Medicine, May 16, 1905, in which they recognized the spirochaeta 
pallida of Schaudinn and Hoffmann as the germ-producing syphilis. 

The spirochaeta which has been referred to the class of trypano- 
soma, either prepared with azur and eosin (Giemsa stain) or with 
nitrate of silver and pyrogallic acid (Levaditi method), appears as a 
filament from four to ten /*, and one-half ^ thick, with narrow spirals 
in the form of a corkscrew, perfectly regular with pointed ends. 

In the spirochaeta^ and connected with them have been described 
small round or oval bodies, which according to Herxheimer are prob- 
ably terminal centrosoma. or initial forms in the development of the 
spirochaeta. 

When examined in a hanging drop the spirochaeta is in motion 
forward and backward, or in a kind of trembling movement, or in the 
form of elongation or of a shortening of the whole filament. They 
are usually found isolated, but often are found in groups. The method 
of staining is that of the Giemsa stain. A cover glass or a slide is 
rubbed on a mucous patch or on a chancre, or better the lesions are 
gently scraped with a curette and the mucous secretion with the 
detritus is taken on the glass slide. When perfectly dry in a film, it 
is hardened with alcohol for a few seconds and then dried again. The 
Giemsa stain is poured on and covered with a glass cover. After 
twenty-four hours it is washed, dried, and examined in cedar oil. The 
true spirochaeta takes a light rose-violet color, while the sp. refringens 
takes an intense blue coloration. 

With the method of Levaditi, the staining is done in the whole 
mass of the syphilitic product, so that it can be cut into sections and 
the spirochaeta is then seen in the midst of the tissues. The prepara- 
tion is as follows : A thin piece of mucous patch or suspected tissue 
is kept twenty-four hours in a ten per cent, solution of formalin, then 
twenty-four hours in a ninetv-five per cent, alcohol, then is left for a 

13 Neisser. " Versuche zur Uebertragung der Syphilis anf Afferi." Pruts. 
Med. Woch. 1906, No. 13. 



12 THE MEDICAL ASPECTS 

short time in distilled water. It is then left for three days in a solution 
of one and one-half per cent, of nitrate of silver, at a temperature of 
38 C, and one day in a solution containing two per cent, of pyrogallic 
acid and five per cent, of formalin. Blaschko, 14 who has used this 
method quite extensively, cautions against local anesthesia in removing 
the piece of tissue by the infiltration with Schleich solution, on account 
of the salt which causes a precipitate with the nitrate of silver. 

Levaditi's method in our hands has given good results, as can be 
seen in the photomicrograph, Fig. I, which was taken from a hyper- 
trophic mucous patch of the vulva in a colored woman. 

Spirochaetae have been found in every tissue and in every fluid 
of the human body affected with syphilis, and not only on ulcers and 
on ulcerated patches, but also in parts far removed from them ; in the 
circulating blood, in dry papular lesions, in the spleen, liver, kidneys 
of children who had died in consequence of congenital syphilis. 

Mercury seems to have a powerful action upon the spirochaetae, 
so much so that after the use of this remedy only a few or none at 
all are to be found in the local lesions. 

This fact suggested to Metschnikoff and Roux 15 the idea of the 
prophylaxis and cure of syphilis, by demonstrating that the inoculation 
of syphilitic virus can be made harmless to man. A few hours after 
inoculating monkeys with syphilitic virus the points of inoculations 
were treated with a salve containing thirty per cent, of calomel, and 
in thirteen experiments the development of the syphilitic lesions failed. 
This experiment was repeated in a student who bravely volunteered 
to be the subject of the experiment. With virus from a hard chancre 
the student and several monkeys were inoculated at the same time. 
A few hours later the place of inoculation in the student and in one 
of the monkeys was treated with the thirty per cent, calomel salve, and 
the others were left as a control. In the student and in the monkey 
where the puncture of inoculation had been treated with the calomel 
ointment there were no signs of syphilitic lesions, while the other 
monkeys showed an initial chancre. 

In late syphilitic manifestations of the skin spirochaetae are not 
easily found. Spitze found spirochaetae in gummata and in sclerotic 
tissues, Rille in small cutaneous gummata, and we could find them in 
the sclerotic tissues of syphilitic elephantiasis of the scrotum. 

In the skin, according to Burnet and Vincent, they are found 
abundantly in the connective tissues, the lymph spaces, and in the af- 

14 Blaschko. " Ueber spirochaeten Befunde in syphilitisch erkrankten 
Gewebe." Med. Klinik, 1906, No. 13. 

15 Metcshnikoff and Roux on the prophylaxis and cure of syphilis. French 
Academy of Medicine. Med. Record, July 7th, 1906. 



Plate I 




Trypanosoma Lues 
Lymph space of the skin from an excised papula full of spiro- 



cnaetae 



objective 



SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 13 

fected tunics of the blood-vessels. Levaditi found them in the epi- 
dermis, in the tonsils, in the endothelial layer of the blood-vessels, in 
the liver in groups surrounding the blood-vessels and in the proto- 
plasma of the hepatic cells. 

Spirochaetae were seen to continue in their movements in the hang- 
ing drops for a few hours. In the cadaver of an infant who had died 
with syphilis, seven hours after death spirochaetae taken from the liver 
maintained their lively movements. After twenty hours there could 
still be seen some slight undulation. 

Cultures on human blood were made by Soura with negative 
results. 

Metschnikoff and Roux are very enthusiastic over this discovery, 
and they tend toward the opinion that syphilis is a chronic spirillosis. 
Indeed, if the spirochaetae were only ordinary saprophytes they would 
be found only on the surface and could not be found in internal organs, 
as has been the case with the spirochaeta. The objection that the 
culture of the micro-organism has not been successful, does not dimin- 
ish the value of the discovery. Many other morbid agents, although 
demonstrated beyond any shade of doubt, have not yet been cultivated, 
as the bacillus leprae, the plasmodium, and the spirillum of recurrent 
fever. If syphilis has been transmitted by means of inoculation from 
the blood in man by Pellizzari, and in the chimpanzee by Hoffmann, 
this is enough proof that spirochaetae live in the blood as a natural 
culture medium. 

The beneficial results which this discovery will bring to suffering 
humanity, and to society in general, can already be foreseen. It will 
solve questions of doubtful diagnosis, and will clear up a great many 
problems connected with hereditary syphilis. The celebrated Colles 
and Profeta laws will be explained. Treatment will be established 
upon more scientific ground, and the choice of intermittent or continuous 
treatment will find its true scientific explanation. The power of ag- 
glutination, of phagocytic action, of immunity in syphilis, will be 
established on a solid basis, and very likely we will possess preventive 
and therapeutic means in the use of a specific serum. 



II 

PATHOLOGICAL PROCESS OF INFECTION 

Syphilis is a contagious disease, which is inoculable through the 
secretions of the pathological products for a certain limited period. It 
is in the nature of a fixed contagium, for the reason that the virus must 
be conveyed and placed directly in contact with an excoriated surface 
of the skin or of the mucous membrane of the healthy person. At 
the point of entrance of the virus local changes in the tissues take 
place, which gradually become noticeable in the form of the char- 
acteristic initial lesion, or hard chancre, which in due time will give 
place to general symptoms of a specific character. The virus is re- 
produced in the diseased organism for a limited period of time, retain- 
ing its contagiosity, which ceases when the disease is dying out. The 
disease at a late period is no longer inoculable from the diseased to 
the healthy person, but it is still transmissible by heredity, and as we 
shall see later, from the developing fetus it is communicable to the 
healthy mother. 

The manifestations of syphilis go on in a continuous progressive 
evolution, and they may last for months, or for years, or even for a 
lifetime. The symptoms are not constant, but they appear in the 
form of relapses, so that the progression of the disease is interrupted 
by periods of latency, when the patient is apparently well. Some symp- 
toms are more persistent than others, and in the different cases the 
symptoms vary according to the different organs and tissues affected. 
In a few cases the manifestations are very obstinate, but in most of 
the cases, especially under a well-directed treatment, syphilis dies out 
after a certain period. 

When the syphilitic virus has come into contact with a scratch, 
or a fissure, or an erosion, or possibly has found its way into a follicle 
of the hair, in a word, has been placed in contact with the lymphatic 
spaces, from that moment the inoculation has taken place, and in that 
locality this recently discovered living organism goes on repro- 
ducing and multiplying. If the virus has been inoculated with other 
micro-organisms, there soon appears an ulceration or an inflammation 
as the result of the other cocci. It is clear that if together with the 
syphilitic virus the virus of a chancroid has been inoculated, this 
will soon develop as a chancroid, and only after three or four weeks 

H 



PATHOLOGICAL PROCESS OF INFECTION 15 

the chancroid which was in the way of reparation, appears hard, and 
soon is changed into a hard chancre. The germs of the syphilitic 
virus require time to proliferate, taking two, three or four weeks to 
form their nest, which shows up at the end of the mentioned time in 
the form of the initial lesion. This time which elapses between the 
inoculation and the appearance of the chancre is the period of incuba- 
tion. The word has been well chosen, indeed it is in the nature of a 
culture. The virus inoculated in an infinitesimal part is there incu- 
bated, proliferates in the lymphatic spaces of the skin, around the blood- 
vessels, or under the mucous membrane. The living organisms which 
constitute the virus produce an irritation, which calls in the presence 
of migrating cells ready to reinforce the fixed cells and exercise a 
phagocytic role. The syphilitic germ, however, is too virulent to be 
overpowered by the cells, and they cannot hinder its multiplication. 
It develops its noxious toxins, which cause the subsiding of the 
reactionary phenomena of the cells to end in a proliferation. The cells 
are in the nature of lymphocytes in an embryonal state and form an 
infiltration which is the base of the hardness of the initial syphilitic 
lesion. 

The form and shape of the chancre depends on the layers of the 
derma or of the mucous membrane affected by the virus. If only 
the superficial lymph spaces of the papillary layers are affected, the 
chancre will be superficial in the form of a diffused erosion, chancre 
parchemine ( Fournier) or in the form of a lentil, papula. But when 
the lymphatic spaces and the vascular net of the whole corium is 
affected, then the chancre will be deep, cup-shaped, with thick edges, 
the classic Hunterian chancre. 

The migrating cells, however, are not able to stop the development 
of the infectious germ, the blood-vessels and the lymphatics surround- 
ing the area of induration already show pathological changes ; their 
tunics show an infiltration of cells, while their endothelium shows a 
proliferation of its cells. In the lymph spaces and inside of the lymph- 
vessels the virus has an agglutinative power on the lymph, which 
nearly closes the lumen of these vessels, and causes a chronic inflam- 
matory process. The virus, consequently, does not remain limited or 
enclosed in the area of the induration, but has already proceeded and 
spread to the surrounding lymphatic vessels, which by a skillful finger 
can be detected to be already hard and infiltrated. The general system 
is not yet aware of that which is developing in the lymphatics : in 
consequence the infected individual is apparently well. No pain and 
no disturbance has so far occurred, nor can any alteration of nutrition 
be detected. Meanwhile the virus is unrelentingly increasing and its 
evolution is continuously progressing and always along the lymphatic 



16 THE MEDICAL ASPECTS 

channels. Here it finds the lymphatic glands, which act as a fortress 
planned for the purpose of preventing the progress of virulent microbes. 
But the same process which has caused the induration in the place of 
the inoculation, occurs in those glands. They become hard infiltrated, 
enlarged, somewhat swollen, but not usually painful, for the reason 
that the inflammatory process is very slow, the reaction is very feeble, 
and the presence of the virus produces an infiltration, the cells having 
lost their phagocytic power. Indeed, the enlarged glands of the groins 
are called bubo, and when resulting from syphilis, syphilitic bubo. 
The differential characters of the syphilitic bubo from the ordinary 
bubo of chancroidal origin are the sluggishness and the tendency not 
to suppurate. In some cases we also find that the syphilitic bubo may 
show signs of inflammatory reaction and suppuration. But in these 
cases the inflammation and the following suppuration are the result 
of other irritating germs, which have been accidentally inoculated 
together with or after the syphilitic infection. 

The glands which are first affected are those which are the nearest 
to the chancre, so that if the chancre is on the genitals the first glands 
to show the induration are the inguinal glands ; if the chancre is on 
the lips, the submaxillary glands will be the first to be affected. 

The time elapsing from the appearance of the chancre to the 
time when constitutional symptoms of syphilis appear has been called 
the second incubation. It is a period which we cannot call one of 
latency of the virus, because the virus is constantly reproducing, is 
advancing every day, is already forming its toxins, which display 
their noxious effects on the blood and on the tissues, but it is more 
a quiescence, the virus is not ready to show up w r ith the character- 
istic eruptions of the syphilitic erythema. When we shall know the 
entity constituting the syphilitic virus and its biochemistry, then we 
may be able to establish the exact influence which it has upon the 
affected organism; so far we must content ourselves with noting the 
changes which are produced in the tissues of the infected system. The 
virus deposited in the tissues of the skin or of the mucous membrane 
excites a cellular proliferation and infiltration in the point of infection, 
which makes the characteristic induration. This cellular infiltration, 
the product of the irritation of the virus, may for a certain time act as 
a kind of barrier preventing the virus from proceeding. In other cases 
the virus may be free in the tissues, and this may be the reason explain- 
ing the earlier or later appearance of constitutional syphilis. 

We have already had occasion to call the attention of practitioners 
to the fact that the manifestations of the constitutional symptoms will 
sometimes come a few days after the appearance of the chancre, while 
in other cases it will appear several weeks later, when the chancre has 



PATHOLOGICAL PROCESS OF INFECTION 



17 



nearly healed up. We find the reason in the difference in the length 
of time of the second incubation, in the origin of the virus. When 
the virus inoculated is the secretion emanating from a hard Hunterian 
chancre, the infection will proceed slowly with a long period of 
second incubation, while when the virus is the result of a humid papula, 
or mucous patch, the initial lesion will be of a papular form, small, and 
rather superficial, but more virulent in its nature. Indeed, we have 
observed in a large number of patients that the appearance of this 
small chancre is soon followed by a roseola, and the constitutional 
symptoms seem to be more severe in character. This is easily explained 
by the greater or less virulence of the infecting secretion, when we 
think that the hard Hunterian chancre is a place of elaboration of the 
virus, where the bacilli are proliferating, and the virus is in progress 
of elaboration and has not yet reached the ripe point. The secretion of 
a mucous patch contains a virus which has already been elaborated in 
the system, which contains toxins already formed, and also secondary 
septic bacteria of the pus and of the putrefaction. In this condition 
we believe that the explanation of the difference is found in the viru- 
lence of the secretions producing syphilitic infection. 

The constitutional symptoms occur only when the virus reaches 
the blood circulation, and we can assume that the virus can reach the 
blood, either by means of the lymphatic channels or by being intro- 
duced into the circulatory system directly from the infected point. 
When carried by lymphatic ways the virus proceeds slowly and the 
appearance of the eruptions is somewhat delayed, but when it is carried 
through the blood-vessels then the secondary eruptions are found 
nearly contemporaneously with the appearance of the initial lesion. 

It is necessary to remark, however, that at the period of the 
chancre the man is not constitutionally syphilitc, but he will become so 
when the virus will have reached the blood circulation. This has 
been shown repeatedly by the post T initial infections, which have been 
made either accidentally or for the purpose of experiment. Haslund, 
Ullmann and Lasch have referred to cases of individuals who, being 
already affected with an excoriated chancre and having had pustules 
on the body from scabies in the vicinity of the chancre, have shown 
other consecutive initial syphilitic chancres as the result of secondary 
inoculations. Pontoppidan experimentally obtained positive results 
by inoculating the secretion of an excoriated initial lesion on the arms 
and abdomen. These facts are apt to prove the views of Lang 1 on 
the possibility of a regional migration and of a post-initial infection. 
And they also prove beyond a doubt that a man affected with an 

1 Lang, E. " Acquired Syphilis." " Twentieth Century Practice," Vol. xviii, 
P- 39- 



18 THE MEDICAL ASPECTS 

initial chancre, although the lymphatic glands are involved, is not 
necessarily constitutionally syphilitic. And he will be so only after 
the virus has reached the general circulation. By means of the blood- 
vessels the syphilitic virus is transported to all parts of the body and 
no organ or tissue is spared, as the syphilitic pathological products are 
found in everyone, especially in the blood vessels. 

Although the syphilitic virus affects every tissue of the organism, 
yet it shows some preference for one or another organ or tissue. In 
this way we find that one patient is troubled with continuous eruptions 
of the skin, while another has scarcely a sign on his body and yet is 
constantly annoyed with ulcerated patches on the tonsils or tongue. 
Other patients who have scarcely shown signs of roseola on their 
body will quickly show symptoms affecting the nervous system, while 
others will be affected with syphilitic periostitis and osteoperiostitis. 
There is no law according to which syphilis attacks one part or another 
of the body, neither is there any established law that syphilis must 
run its periods in succession as set forth in the text-books. But we 
can say that in the generality of the cases there is a certain order of 
symptoms showing an irritative character in the first period of con- 
stitutional syphilis, while symptoms of a proliferating or of an infiltrat- 
ing nature mark the later period of the disease. 

Ricord established the division of the periods of syphilis into sec- 
ondary and tertiary. Although it has been severely criticised, yet it is 
based not only on the chronological order of the symptoms, but on the 
physiological and pathological conditions. Rinecker 2 showed the 
faculty possessed by secretions from secondary syphilitic lesions of 
reproducing the disease when inoculated in healthy persons, and the 
apparent non-inoculability of the tertiary manifestations, by means of 
experimental inoculations. This forms the basis for the distinction 
from a physiological point of view. The pathological distinction was 
at first pointed out by v. Barensprung 3 that the secondary syphilitic 
manifestations were the result of hyperemia and of a simple exudation, 
while the tertiary forms consisted of infiltrated nodules. 

In this way the distinction of Ricord, which was believed to be 
based only on a supposed chronological order of symptoms, became 
solid on a scientific basis and as a consequence a simple exudative iritis, 
orchitis, periostitis, and even superficial cutaneous ulcers, were dis- 
tinguished from gummatous affections, which have found their place 
among the tertiary lesions. 

In constitutional syphilis besides the symptoms of irritation, in- 

2 Annalen der Charite, vi, p. 56. 

3 Virchow, R. " Ueber die Natur der constitutionell-syphilitischen Affect." 
Virchow Arch, fiir path. Anat. u. Phys. 15 B. 



PATHOLOGICAL PROCESS OF INFECTION 19 

flammation and proliferation, there is an order of alterations revealed 
in the nutrition of the organs and tissues in the form of marasmus in 
syphilitic cachexia. Ricord found the explanation of this condition 
in the diminution of the blood corpuscles resulting from a quicker 
destruction of them through the deleterious action of the virus, and in 
a diminished faculty of the hematopoietic organs in the formation of 
new corpuscles. Oligocythemia can be considered the result of the 
altered condition of the lymphatic glands. 

In connection with syphilitic cachexia there have been found in- 
durations in different organs of a lardaceous, waxy, or amyloid de- 
generation by Rayer, Rokitansky, Dittrich, Meckel and then proved 
by Virchow with the iodin reaction. 

The secondary stage begins with the first cutaneous erythematous 
manifestation, which is preceded by a prodromic period, which makes 
syphilis resemble exanthemata. Indeed, patients complain of rheumatic 
pains affecting different joints, together with general malaise, dull 
feeling of the head, pains in the chest, no ambition to pursue their 
occupations : some have insomnia and at times also neuroses. Under 
these conditions fever often appears, which we consider as syphilitic 
fever, because it is the result either of the chemical products emanating 
from the metabolism of the syphilitic micro-organisms, or from prod- 
ucts of disintegration of the blood or of the tissues, which in the 
general circulation are liable to produce this peculiar pathological 
symptom of general reaction. 

It seems that the syphilitic virus which has been formed in the 
initial lesion, and from there has been stored into the lymphatic glands, 
enters the blood circulation in small quantities and in successive issues, 
so that the general system, although affected, yet shows no reaction on 
account of the small quantities of the virus. From this we see that in 
some cases the syphilitic eruptive symptoms are preceded and also 
accompanied by fever, while in other cases the eruptions are ushered 
in without pyrexia. 

It is difficult to say whether this high temperature of the fever 
exerts any influence on the bacilli in increasing or in diminishing their 
virulence, rendering the course of syphilis milder or more severe. In 
our last term in the hospital we had occasion to see a man who entered 
the institution on account of acute rheumatism, but, still having a 
chancre on his glans penis, in the way of reparation he was referred 
to our ward. He was confined to his bed, as he could not move a joint 
on account of excruciating pains which had attacked the whole body. 
The joints, however, although extremely tender, did not show any 
perceptible swelling, such as we find in cases of acute rheumatism, nor 
could we find any perceptible exudation in the serous membranes of 



20 THE MEDICAL ASPECTS 

the joints. The fever was remittent in character, the temperature 
ranging between ioo° to 103 ° F., increasing towards night time, when 
the pain also became more intense. The administration of the salicylate 
of sodium did not relieve this condition, and as the roseola in large 
patches was appearing on his chest, back, arms and thighs, we resorted 
to deep injections with one per cent, solution of sublimate, and to a 
saturated solution of potassium iodide internally, in doses of ten drops 
every four hours. In a few days the patient was able to leave his bed. 

The treatment was continued with sublimate injections, stopping 
the use of the iodide, and in a short time the roseola disappeared, leav- 
ing a mild erythema on the soft palate and tonsils. The patient was 
feeling well and asked to be discharged to return to his occupation. 
He was instructed to continue his treatment of liquor VanSwieten 
for some time longer, and in case of a new eruption to call at the 
clinic, but he did not come under observation again. 

In this case we found that syphilis which had produced so deep and 
a severe general symptoms as to cause high fever and a severe 
attack on the serous membranes of the joints, had exhausted its 
strength and in a short time had yielded to the treatment. This 
observation is in accordance with the experience of Lang, 4 who claims 
to have frequently observed that intercurrent febrile diseases, such as 
pneumonia, erysipelas, smallpox, typhoid fever, or acute articular rheu- 
matism, occasionally exert an extraordinarily favorable influence on the 
syphilitic process. 

This fever, which marks the first constitutional symptoms of 
syphilis, is the true syphilitic fever, which has nothing to do with 
fevers arising late from gummatous ulcers, or from osseous complica- 
tions, due to the action of the common pus cocci. 

The idea of the syphilitic virus being emptied into the circulatory 
system in a large quantity, thereby causing feverish reaction and putting 
to work all the resources of the organism to free the system from it, 
finds another comparison with the whole phenomenological course 
of syphilis. In fact, patients who have suffered with severe manifes- 
tations on the skin and mucous membranes, in ordinary circumstances 
do not show cases of severe cerebral syphilis. And the contrary has 
been remarked by neurologists that severe cases of spinal and cerebral 
syphilis are found in patients who had suffered from very mild cases 
of syphilitic eruptions. In these cases the syphilitic virus would reach 
the blood only in a very small quantity, remaining latent in the system 
until it produced the most distressing alterations in the deeper organs 
and tissues. 

Returning to this fever, which we consider as the invasion fever of 

4 " Twentieth Century Practice," Vol. xviii, p. 42. 



PATHOLOGICAL PROCESS OF INFECTION 2 I 

syphilis, we cannot fail to recognize a peculiar type, which makes it 
resemble malarial fever. Indeed, patients affected with secondary erup- 
tions have been quite often referred to malaria before the eruption had 
taken place, and we have often seen patients take quinine for this fever 
under direction of their family physician. Fever does not accompany all 
cases of syphilis, in many cases the patient has had no fever whatever, 
and he is aware of the presence of the roseola when the physician invites 
him to undress. In the cases, however, where the fever is marked, we 
find that it makes its appearance from six to eight weeks after the infec- 
tion. The fever rarely begins with a chill, but usually is noted by such 
a heavy headache, malaise, general depression and rheumatoid pains, 
that the patients take to their beds. It has a remittent type, so that the 
temperature is lower in the morning and higher in the evening, some- 
times reaching, according to Lang, 105 ° F. It lasts two, three, or four 
days, rarely longer, and after a couple of days the skin shows a diffused 
faint redness, which in a few hours gives place to the roseolar erup- 
tion. After the eruption has made its appearance the fever soon sub- 
sides, leaving, however, the general symptoms, which only gradually 
disappear. 

We have shown how a man who had been infected with syphilitic 
virus, which had proliferated, found its way through the lymphatic 
channels, reached the blood, reproduced the entire syndrome of the 
syphilitic exanthema. We now know beyond any doubt that the man 
or woman is syphilitic, that they have acquired syphilis, but we do not 
know what will come later. We do not know how they have become 
infected, whether by guilt or by accident. It is quite interesting for 
the physician to know the origin of the infection, and establish the 
point of entrance of the syphilitic virus. In order to reach this knowl- 
edge, we must consider the different ways in which the inoculation can 
take place. 



Ill 

MODES OF INFECTION 

Syphilis is transmissible from a syphilitic person to a healthy one 
by direct contact of the secretion exuding from ulcerations of syphilitic 
inflammatory products, or from his secretions (sperma), or from his 
blood inoculated on a scratch, or on an abrasion, or on a wound in the 
healthy individual. In this case the syphilitic virus produces at the 
place of entrance its initial lesion in the form of a hard chancre, as 
stated above. The large majority of cases of syphilis are acquired 
during coitus with a syphilitic person, and the seat of the initial mani- 
festation is usually the genitals or their vicinity in the form of genital 
or paragenital initial lesions. As a consequence we find the hard 
chancre in the man on the inner surface of the prepuce on the sulco- 
balano preputiale, on the frenum, on the free edge of the prepuce — on 
all those parts where the thin epithelium is liable to be torn or scratched. 
Not infrequently the initial lesion is found on the skin of the penis 
dorsi, and on the inferior region just at the point of juncture with the 
scrotum. In the woman the initial lesion often has its seat on the 
nymphse or on the internal surface of the labia majora, on the four- 
chette and at the ostium vaginae. 

The initial lesion besides the genitals is found quite frequently on 
the mouth, on the lips, on the tongue, on the tonsils. The virus has 
been deposited there by kissing, or by using some article which had 
been in the mouth of a syphilitic, such as pipes, stumps of cigars, 
glasses, spoons, forks, etc., or through unnatural contact with the 
genitals. 

An initial lesion is also found on the lips of children who have 
been kissed by syphilitic persons, or of infants who have been nursed 
by a syphilitic woman and has, vice versa, been found on the breast of 
nurses who have suckled syphilitic children. 

An initial lesion has often been found on the eyelids, sometimes on 
account of kissing, and at other times on account of foreign bodies 
being removed from under the eyelids by licking the eyes, as is cus- 
tomary among Russian peasants. 

We have seen three cases of hard chancre of the chin, in two the 
virus had entered through a scratch from a razor in shaving, and in one 

22 



MODES OF INFECTION 23 

the virus had entered into the follicles of the hair. In all the three 
cases, the face had been besmeared with the saliva containing secretion 
from mucous patches or from the blood oozing from the excoriated 
patches on the lips of a syphilitic woman. In another case of chancre 
of the chin the inoculation resulted from a pair of tweezers used by the 
barber to remove a hair growing under the epidermis. 

Initial lesions in the mouth have been the result of inoculation of 
syphilitic virus from surgical instruments, especially those for dental 
operations. Vice versa, we have had occasion to see numerous cases 
of hard chancre upon the last phalanges of the second finger of the 
right or of the left hand of dental students, and of dentists, acquired 
while performing dental operations. We have quite often had occasion 
to give professional attention to physicians, midwives and nurses, who 
had accidentally become infected in pursuing their duties. As a conse- 
quence, when a patient comes before us, he has been infected with 
syphilis either by his own fault, exposing himself to the contagium by 
coitus, or by accidental infection. In one way or the other he has 
acquired syphilis, but in one case the responsibility rests with himself, 
and in the other it is entirely foreign to his will, having been inoculated 
by accident without any suspicion. 

In the case of a guilty one, there are two classes of infected per- 
sons. One is the street rowdy who is accustomed to carousing and is 
almost certain to get syphilis. Such libertines ought to be confined in 
a hospital, as prostitutes are, in order to prevent them from spreading 
the disease. They belong to the lower classes, without principles of 
morality, who are addicted to the abuse of alcoholics, which makes 
their syphilis of a malignant nature. Deteriorated by debauchery, 
weakened by the use of alcoholics, their system is an easy prey to the 
tertiary symptoms of syphilis. Their dissipated lives and immoral 
customs find severe punishment in syphilis. They form the popula- 
tion of the venereal wards and are subject to the severest ravages of 
the gummatous period of syphilis. This class of patients frequently 
comes before the Judge of Police Court, and they are the tough cus- 
tomers of the workhouse. 

Another class of patients we find belonging to guilty ones, who 
with the best education, with the best moral principles, have forgotten 
themselves in an unfortunate moment. They have been infected with 
syphilis by coitus. They remember that moment as the darkest spot 
of their life. They long to go back of that moment, and feel that 
they never will be guilty again of such an indiscretion. They find 
themselves infected with a loathsome disease, and are disgusted with 
themselves. Uusally they are intelligent patients, well educated, and 
are made despondent over the occurrence, and see the future before 



24 THE MEDICAL ASPECTS 

them dark and full of dismay. They see the danger of hideous 
eruptions on their faces, which are noticed by everybody, and they fear 
that on their foreheads may appear that horrible corona veneris, by 
which everyone may read their guilt. They understand the danger 
of inoculating others, and especially the danger of inoculating 
the wife in case of marriage. They foresee, too, the horrible 
inheritance which will be transmitted to their offspring, and they 
feel the remorse, fear the consequences, and subject themselves to 
the most exact and thorough treatment. They are the most obedient 
patients, they quit the use of tobacco and of any stimulants, and will- 
ingly submit to any remedy in order to recover from their syphilis. 
In many cases they become neurasthenic from great worry over their 
unfortunate accident. In the daily papers we sometimes read of 
suicides, or of the disappearance of individuals without any special 
cause ; frequently the cause is given as financial distress. Syphilis is 
never thought of nor mentioned, but on many occasions it is undeniable 
that it may be a cause, if not the principal one, for the disappearance or 
the suicide. It plays a great role in domestic dramas, of which the 
solution usually remains a secret. Fournier has already referred to a 
dozen cases of suicide committed on account of syphilis. 

A gentleman in high professional standing, with a splendid scien- 
tific education, of an irreproachable moral character, on not feeling 
well, sent for us professionally. He called our attention to a small, 
hardened point in the sulcus balano-preputialis, which was diagnosti- 
cated as a hard chancre. Our poor friend was thunder-stricken, he 
looked at us in the hope that we had made a mistake, but after a more 
careful examination the diagnosis was confirmed. He was to get 
married in a few weeks, everything was ready, the cards already 
printed, what could he say? what excuse could be found to satisfy the 
curiosity of his acquaintances? 

It was a question of breaking off the engagement, or postponing 
the marriage, until when? The following dilemma arose, either break 
the engagement, or give his wife a case of pox as a wedding present. 
What horrible nights he was passing, nights which were as long as 
eternity. The light of day, the ordinary occupations distract the mind 
from continuous thought ; but when night came, the darkness presented 
the most distressing scenes to his mind. Sleep was impossible, and if, 
for a moment, he began to doze, he was awakened by the most frightful 
dreams. 

Yet the end of the trouble was rather satisfactory. The only 
constitutional symptoms were limited to a mild roseola, and a few 
superficial patches on the tongue, which, with a vigorous and well di- 
rected treatment soon disappeared. The marriage, which had been 



MODES OF INFECTION 



25 



postponed on account of ill health, was celebrated over two years after 
the occurrence, nearly sixteen months after that no more symptoms had 
reappeared. We never heard of any further trouble on this account. 

In the case referred to, we find an act of misguided conduct which 
had produced bad results, and for which he paid the penalty of his 
imprudence. It is true that each individual case must be judged by 
a charitable regard for the preceding and subsequent conduct, but in 
those cases we find that the moral responsibility is greatly diminished. 

We have another series of cases of syphilitic inoculation, where the 
individual has no idea of exposing himself to the possibility of being- 
infected. This is the case of a woman who has married a syphilitic 
husband and she is infected with syphilis without knowing it. This 
subject is of vast importance, and will be treated separately in the 
article referring to marriage. Other modes of infection are possible 
without any knowledge. 

We were asked to see a lady for a so-called abscess of the nipple. 
She had given birth to a healthy child, but fearing she had not a 
sufficient quantity of milk to feed it, the child had been given to a wet- 
nurse. After several weeks the baby developed a sore mouth. The 
mother still wanted to nurse her child. A physician had seen the child 
and failed to make a correct diagnosis, in consequence the mother kept 
on suckling her babe. After a few weeks, the mother developed a sore 
nipple, which was taken for an abscess and for which our advice was 
sought. This sore nipple was a hard chancre of the classical type, 
and a roseolar eruption was already perceptible on her chest and back. 
It was a case of unmistakable syphilis, and it was, therefore, not diffi- 
cult to trace the origin of the inoculation. The sore mouth of the babe 
consisted of mucous patches on the lips, and an examination of the 
nurse revealed the whole history of the transmission of syphilis. The 
fault of the contagium in this case rested only on their family physician, 
who had been called to examine the nurse before having her give her 
breast to the babe. His examination had not revealed to him the 
presence of syphilis in the nurse, and this threw on him all the blame 
for the infection of the whole family. 

We have had occasion, in another instance, to see just the reverse 
in the syphilitic infection. To a healthy nurse was given a syphilitic 
babe for nursing, without anything being mentioned concerning the 
existence of this disease in the family. The nurse became infected, 
and after a few months was allowed to return to her native village. 
Her husband became infected, and a small epidemic of syphilis started 
in that country place which was traced to her. In small proportions 
it recalled that which happened on the first appearance of syphilis 
among the European populations, when syphilis became almost epi- 



26 THE MEDICAL ASPECTS 

demic. In that case, although the origin was in a guiltless person, yet 
the following cases were equally in the guilty and not guilty, without 
distinction. 

We cannot leave this subject without referring to an experience 
which we had only a few months ago. We were called in consultation 
to see a babe four months old, which was suffering with supposed 
eczema. The child was covered with a papular eruption from head to 
foot; on the face, around the nose and mouth, and alsd around the 
genitals and the buttocks, the papules had been excoriated and in con- 
sequence were covered with thick crusts. There was no doubt that 
the case was one of a papular syphilide, the only question was to trace 
the origin. The child had been nursed by the mother alone, and she 
was apparently in splendid health. The father, although in apparent 
good health, admitted that he had a small chancre before his marriage. 
The sister of the mother came to help her in taking care of the babe, 
which she did with good will and self-denial. Not long after she 
sought our advice for an ugly pimple which had appeared on her right 
cheek. It was a hard chancre, which she had contracted from the 
babe of her own sister, and she has had all the manifestations of con- 
stitutional syphilis. Here we have a case of infection directly due to a 
good heart and to altruism. 

The cases of accidental syphilitic infection can be multiplied to the 
infinite, and this has caused the authors to form a class of cases of this 
disease which has been called Syphilis Insontium, because the infected 
is entirely innocent in the acquiring of syphilis. L. Duncan Bulkier * 
has given great consideration to this subject, and after a careful study 
of the literature, shows that the disease has been acquired innocently 
in a vast number of instances, and in ways and means which could 
hardly have been suspected. Fournier stated that nearly twenty-five 
per cent, of females with syphilis met in his private practice had ac- 
quired the disease in a perfectly innocent manner. Bulkley produces 
long statistical tables of initial lesions of syphilis observed in genital, 
perigenital and extragenital regions. In all these tables the frequency 
of the accidental infection through the mouth, fingers and vaccination 
is remarkable. Nearly every year Bulkley refers to cases of this kind, 
illustrating this important subject, and such work ought to change the 
idea of syphilis among the laity and the profession. 

Everyone, in his practice, has occasion to refer to cases of syphilis 
acquired in the exercise of one's profession, cases which may be called 
professional syphilis. We have already had occasion to report three 
cases of hard chancre on the lips in three workingmen employed in a 

1 Bulkley. " Syphilis Insontium : A Clinical and Historical Study of 
Syphilis Innocently Acquired." New York, 1893. 



MODES OF INFECTION 27 

glass factory. They had been infected by using the blow tube to blow 
the melted glass and make bottles. Nearly every year we meet with 
cases of intial lesions of syphilis, in the fingers and hands of physicians, 
dentists and midwives. The introduction of the fingers into the mouth 
and the vagina for examination is the most dangerous feature in our 
profession, on account of the possibility of being infected. 

In these cases we find that the unfortunate occurrence of taking 
syphilis has been the result of altruism, either in being useful to others 
or in the performance of duties connected with one's occupation. It 
is an act of self-denial which leads to sufferings and to physical en- 
feeblement, and which may be of disastrous consequences for his wife 
and offspring also. The syphilitic infection in many cases may weaken 
a wide-awake mind and the constitution of a vigorous body, which will 
diminish the happiness of his descendants, who, having inherited a 
syphilitic taint, are bound to undergo sufferings which diminish the 
pleasure of living, In fact, a well-preserved life shows itself in over- 
flowing spirits, becomes a source of pleasure to all around, while a 
constitution weakened by the presence of the syphilitic virus, or by the 
fear of being syphilitic, brings depression to him and to his family. 

In conclusion, we have seen that a young man may expose himself 
to the danger of infection from syphilis on account of his indiscretion, 
and for this he has to bear the blame and the penalty. This indiscre- 
tion, however, has no connection with a deterioration of his moral 
character, although he has been late in determining that he will never 
do it again. We have seen many others infected with syphilis in 
complying with their good and charitable nature, or with the duties of 
their profession, and this class of patients ought to be considered as 
sufferers on account of their humanitarian altruism, rather than have 
a suspicious look cast on them because of their being infected with 
syphilis. 



THE EVOLUTION OF SYPHILIS 

IV 

PRIMARY SYPHILIS 

The different ways in which syphilis may be acquired make a dif- 
ference in its reflex upon the morality of the infected, but with refer- 
ence to the evolution of the disease, do not change at all the virulence 
of the infection and the consequent manifestations. Neither does this 
exclude the fact that every individual infected is a possibility for 
spreading the disease among others, for the virus taken in any way 
will produce the same results in the newly infected. 

In a person free from syphilis, when the syphilitic virus comes in 
contact with an abrasion, scratch, puncture, or finds its entrance in a 
follicle, there the initial lesion is formed, which is nothing else than a 
culture of the syphilitic germs. The initial lesion, in the form of a 
so-called hard chancre, appears only after a certain period of time, 
which is called incubation, and it is truly an incubation of these germs 
(spirochaetse), which takes an average of from three to four weeks to 
show its work. 

In the event that, together with syphilitic virus other germs of a 
different kind and virulence are inoculated, we have some difference in 
the manifestation of the chancre. But when syphilitic virus contains 
no other virulent germs, then after the mentioned time a circumscribed 
infiltration is noticed just at the place of entrance of the virus, which 
is marked by a slight redness and sharply defined borders, hard to the 
touch, accompanied by a slight sensitiveness. This is the classic in- 
durated chancre, or the Hunterian chancre. At other times the chancre 
is much more superficial, little elevated about its edges, which seem to 
be nearly encased .in the normal tissues, chancre parchemine, initial 
papule. The difference is only in the depth of the tissues involved 
in the process ; the alterations are found in the lymphatic and in the 
blood vessels of the affected skin or mucous membrane. These altera- 
tions are to be found in all local syphilitic manifestations, beginning with 
the initial sclerosis, and persisting in the infiltrated gumma of the late 
manifestations. 

The chancre histologically is the result of an infiltration of cells 
into the lymph spaces around the connective tissue fibers of the mucous 

28 



PRIMARY SYPHILIS 29 

membrane or of the derma. Macroscopically it appears like a granular 
amorphous substance, and from the fact that it takes a reddish color 
with iodine, von Barensprung thought that the exudation forming the 
base of the specific induration was different from other inflammatory 
products, and to be identical with those exudations, constituting in- 
filtrations in the organs in consequence of constitutional syphilis. But 
Virchow proved that degenerations are present in many pathological 
processes, and they show nothing characteristic in syphilis. 

In the first moments after the inoculation, the syphilitic virus 
germinates into the lymph spaces as the parts which offer the soil 
adapted for the development of the germs. In some specimens of the 
initial sclerosis, greatly enlarged lymphatic vessels surrounded by a 
large quantity of infiltrating cells have been found. The lymphatic 
vessels are affected by an inflammatory process, their endothelial cells 
are enlarged and in some places detached. The lymphatic vessels start- 
ing from the initial sclerosis are also enlarged, and show irregular 
dilatations during their course in the form of a cul-de-sac, and are filled 
with mononuclear leucocytes. The inflammatory condition of the 
lymphatic vessels is very perceptible, and clearly shows that the indur- 
ated edema, which often accompanies the initial sclerosis, is due to the 
occlusion of the lymphatic vessels. 

The infiltration which forms the body of the hard chancre seems 
to be circumscribed in a focus, as it is limited by a strong layer of 
elastic fibers ; the process, however, has a tendency to spread through 
the lymph vessels. In the further development of the chancre, the 
blood vessels too are involved in the infiltration, and their walls show a 
process of chronic inflammation with an enlargement and thickening 
of their stroma. These pathological changes are found in the arteries 
as well as in the veins, and it forms the characteristics of all syphilitic 
lesions. 

In the sclerotic part the new cells are forced towards the surface 
and the epithelial stratum appears thinner, and gradually the affected 
part appears deprived of its epithelium (eroded chancre) ; or it breaks 
down entirely (ulcerated chancre). In an old chancre there have been 
found giant cells like those in a gumma. The infiltration takes place 
in the papillary layer, extending sometimes to the subcutaneous tissues. 
The papillae are usually somewhat more elongated and enlarged, with 
an interpapillary ingrowth of epithelium. 

The syphilitic chancre occurs as an infiltrated place from the size 
of a lentil to that of a twenty-five cent piece, encased in the skin or in 
the mucous membrane, with its edges projecting somewhat above the 
level, and of reddish blue color. The anatomical structure of the part 
where it has its seat is the cause of its different shape. When it is on 



30 THE MEDICAL ASPECTS 

loose skin, as on the prepuce, it has that plate-like extension, and it is 
easily recognized when taken between the thumb and index finger, as a 
cartilaginous induration. When near the sulcus balano preputiale, on 
turning the prepuce, the mucous membrane appears yellowish and 
bloodless, like the conjunctiva on the tarsus, when the eyelids are 
turned. 

The chancre can have almost any shape or form, circular, semi- 
circular, cylindrical, beanlike, but always gives that hard, well-defined 
sensation of its edges which constitutes its character. In more resist- 
ant tissues and in less accessible parts, the diagnosis of the hard chancre 
is not so easy ; but from its symptoms and surroundings it cannot be 
mistaken. The hard chancre gradually shrinks and heals up, sometimes 
leaving an indurated place, which lasts for years. At other times it 
undergoes a rapid retrogression so that there remains of it no more than 
a whitish atrophic scar. It is on account of the mildness and of the 
triviality of the symptoms that it may pass entirely unobserved, and 
that the patient, in good faith, denies the existence of an initial lesion. 

The chancre, sometimes on account of the pyogenic cocci, soon 
becomes ulcerated, and the ulcer assumes large proportions. In the 
ordinary cases it has only erosive or ulcerative characters, and the secre- 
tion is rather scanty, shiny and containing detritus. The ulceration is 
always limited by the induration, and for this reason the edges are 
adherent, and the ulcer is deeper in the middle. 

In some cases we have a true gangrenous process extending over 
the indurated chancre, which is explained by the presence of endoarter- 
itis, the result of the syphilitic process. In one case of an old man over 
seventy years of age, who contracted a hard chancre, it was soon 
changed into a gangrenous eschar and invaded nearly the whole penis, 
with fatal results. 

Cleanliness has a great deal to do with the ulceration of the hard 
chancre. It is easily understood that when a purulent secretion re- 
mains between the mucous membrane and the chancre, it will increase 
the irritation, and the inflammatory process will soon increase the 
necrotic process. It will also lead to complications of lymphangitis, 
erysipelas, swelling and redness of the contiguous skin. Quite fre- 
quently in the hospitals we meet with cases of phimosis caused only by 
the inflammatory process of the prepuce on account of the lack of clean- 
liness on the part of the patient. 

The ulcerated chancre, if improperly treated, may be filled with 
exuberant granulations, and, in some cases, they may attain such pro- 
portions as to form true condylomata, or venereal warts. 

In some cases the syphilitic virus may be mixed with other bacteria 
besides those of the pus, as occurs when, with the syphilitic secretion, 



PRIMARY SYPHILIS 



31 



there is mixed the secretion from a chancroid. This case has gfiven 
origin to the theory of the unicity of the virus, and it has taken years 
of constant work to dispel these ideas from the mind of the syphilol- 
ogists. This case was well explained by Rollet, with the mixed 
chancre, which was strenuously denied and fought until the bacterio- 
logical works of Ducrey and Unna, have shown beyond a doubt the 
peculiar dumb-bell bacillus to be the cause of the chancroid. 

In this case the virus of the soft chancre works on its own account, 
producing the chancroid after a very short period of two or three 
days' incubation, and assumes its course as a true chancroid. But when 
the process of reparation begins and the ulcer is healing, then the 
syphilitic virus shows up its work, with the characteristic induration 
around the healing surface of the chancroid. These cases are not rare, 
and they do not reflect much credit upon the physician when he has 
made a diagnosis of chancroid and it finally has turned out to be a 
hard chancre. 

In some cases when the chancre is in the sulcus balano preputiale, 
and is accompanied with lymphangitis and consequent phimosis, the 
diagnosis cannot be easily made ; but the presence of a hard point inside 
of the preputial sac will give the idea of the presence of an ulcerated 
hard chancre. When the initial lesion has its seat in the urethra, it can 
also be discovered by pressing the urethra with the fingers. An 
encio-urethral chancre does not form very deep in the urethra. It 
usually extends from the meatus to the fossa naviculars, or a little above 
the fossa navicularis. It is soon eroded and discharges a mucopurulent 
fluid, which would lead one to think that he had to do with a case of 
gonorrhea, although it is found to be too long after the exposure, and 
lacks the ordinary symptoms of gonorrhea. But the fingers will dis- 
cover a hard point inside of the urethra of an oblong shape, which gives 
the impression of a cylindrical or spindle-shaped hardening of the 
urethra. 

Many kinds of initial lesions have been described ; but so many dis- 
tinctions pertaining to the same thing, instead of contributing to the 
clearness of the subject, will rather make it obscure. Before leaving 
these few remarks on the initial lesion, we wish to consider the other 
kind of initial lesion, which we have pointed out as the initial papule. 
This form of initial lesion is somewhat rarer than the other, and it ap- 
pears after a period of incubation in the form of a small, sharply defined 
nodule the size of a ten-cent piece ; at other times it spreads somewhat 
more. The edges, however, are always projecting - and can be felt hard 
as parchment. The different anatomical regions occupied by the lesion 
are the cause of giving it a different appearance. In a dry part of the 
skin, it will appear as a flat, dry, circumscribed, bluish red livid nodule. 



32 THE MEDICAL ASPECTS 

somewhat hard, its epithelium, macerated by moisture, becomes dry and 
with some little exudation forms a crust which covers its surface. 
When it has its seat on parts of the skin which are usually humid on 
account of physiological or pathological secretions, then the epithelium 
covering the papule soon becomes macerated, and remains like a dirty 
mass of detritus adherent to its surface. On the mucous membranes 
the papule is little elevated above the normal mucosa and the epithelium 
appears like a whitish scab, which, when detached, leaves a red slightly 
bleeding surface. In any place, it has a tendency to break down and 
leave an ulcerated papule, which always becomes more inflamed through 
uncleanliness or misdirected treatment. 

When properly treated, an initial papule heals up, like the other 
initial sclerosis, the infiltration is reabsorbed, the redness diminishes in 
intensity and is changed into a brown pigmentation. This after a while 
disappears and the healed surface shows a whitish atrophic scar, which 
in most cases remains for the whole life, producing, however, no per- 
manent traces of destruction in the affected parts. 

The question arises whether the hard Hunterian chancre and an 
initial papule come accidentally or through some reason. We had al- 
ready noticed in our practice that among a large number of patients, 
some affected with a typical Hunterian chancre, showed symptoms of 
constitutional syphilis much later and somewhat milder than another 
affected with an initial papule. 

It is true that syphilis, like any other disease, is often modified 
in its symptoms and its course, and in its periods of evolution by 
different circumstances. Climate, age, physical condition of the patient, 
incidental diseases, use of intoxicant liquors, timely and convenient ad- 
ministration of therapeutic means, have great influence on the develop- 
ment of the constitutional symptoms. But the source of the infection 
plays a role in the consecutive manifestations of syphilis. 1 The virus 
from a hard chancre needs a solution of the epidermis in order to be 
inoculated, while that which oozes out of the mucous patches can find 
its way in the follicles also. In the case of a hard chancre, the result 
of the virus taken from another hard chancre, the initial lesion is the 
place of elaboration of the virus ; while in the case of the initial papule 
the virus has been already elaborated, and is much more quickly 
absorbed into the system. 

Any virus passing through the animal system is modified in its 
intensity and its effects, and by analogy syphilitic virus is susceptible 
of important changes. The mucous patch, papula Immida, is a char- 
acteristic eruption of syphilis, which appears at its acme, and contains 

1 Ravogli, A. " The initial lesion in relation to the constitutional symptoms." 
Cincinnati Lancet-Clinic, Nov. 24, 1894. 



PRIMARY SYPHILIS 33 

the virus in all its intensity. While at a late period syphilitic mani- 
festations, such as broken-down gummata, have no longer the faculty 
of inoculating the disease, although the affected person is still immune. 
The virus, at the time of the secondary eruptions, is in the full strength 
of its toxic power and the mucous patch, which constantly accompanies 
all the secondary period, is the most dangerous eruption for the trans- 
mission of syphilis. According to our observations the symptoms 
following the inoculation of the virus from one lesion, or from another, 
show some difference in the development, course and severity of the 
manifestations. From our observations we believe that the virus of 
an initial chancre taken from another chancre remains hidden a long 
while in the lymphatic system, where it is elaborated until it is ready 
to produce systematic troubles ; while the virus from mucous patches, 
which is the result of secondary lesions, is more readily absorbed into 
the general system, producing quick and marked symptoms of the 
constitutional disease. 

Marston, Low, Paget, and LIutchinson are of the opinion that the 
more extensive the initial sclerosis is, the more severe and stubborn 
the secondary symptoms that follow. But this assertion does not find 
confirmation in our observations, as we have seen large diffused 
chancres, and sometimes two or three chancres in the same patient, 
followed by mild secondary symptoms which easily yielded to treat- 
ment. On the other hand, we have seen a small initial lesion in the 
form of an initial papule, followed by severe constitutional symptoms. 

Our observations are supported by those of Ed. B. Bronson, 2 
that in the malignant forms of syphilis the symptoms are generally 
precocious. The period of incubation in severe cases of syphilis is 
usually shortened, and the constitutional manifestations hastened. In 
those cases where the secondary symptoms are much delayed, these 
are usually of a mild character. Consequently we are justified in 
regarding a prolonged primary period as a favorable element in the 
prognosis, and a short duration of this period as an unfavorable one. 
The origin of the virus may have some influence in the severity of 
the following symptoms. This, however, must not be considered in 
an absolute way, but must be regarded as subordinate to all the patho- 
genetic causes, which render the system of the patient more or less 
susceptible to the action of the virus. 

It has been pointed out as an important characteristic of the 
initial chancre that it is single, but it is not rare to find two or even 
three chancres, sometimes in the vicinity of one another, sometimes 
widely separated. At the moment of the inoculation of the virus 

2 Bronson, E. B. " Primary Syphilis. A System of genit. urin.," etc. Prince 
A. Morrow, 1893, P- 97- 



34 THE MEDICAL ASPECTS 

several places may have been abraded, excoriated, ready for the ad- 
mission of the virus, and in this way the inoculation may be effected 
in different places. It is also possible that the syphilitic lesions are 
genital and paragenital, and in this way occur a double inoculation 
of the virus at a distance from one another, as has been referred to 
by Jonathan Hutchinson, Ohmann-Dumesnil, Lang, and others. 

Most of the cases of infection take place during sexual connection, 
for this reason cases of genital chancres are more frequent. But, as 
any part of the body having an excoriation exposed to the absorption 
of the virus can be inoculated, so the occurrence of extragenital 
chancres is also equally frequent. Infection through the mouth, bv 
kissing, by using pipes or stumps of cigars has quite often shown 
initial lesions of the lips, corners of the mouth, tongue, tonsils and also 
the face. We have often found chancres on the hand, fingers, and 
several times under the finger nails. We have quite often seen chancres 
on the nipples, cheeks, chin and once on the left nostril. In one 
instance, a hard chancre was on the region of the glabella, and fol- 
lowed a wound with a broken glass. 

Subjective symptoms accompanying the hard chancre are greatly 
influenced by the anatomical region and its functions. A chancre of 
the lips or of the tonsil will be painful during eating or in the act of 
deglutition. A chancre under the finger nail is always painful on 
account of the distention of the tissues, and is often mistaken for 
panaritium. 

The initial lesion, either in the form of sclerosis, chancre or initial 
papule, is always the first symptom of the inoculation of syphilis, 
and we can say that it never fails. However, we find ourselves in 
the presence of cases where the initial lesion has been so slight that 
it has passed entirely unobserved. In women infected by the semen 
or by conception, the initial lesion is not found, and in these cases 
very likely the syphilitic virus has been readily introduced into the 
blood without a chancre or an initial lesion. 

In many cases the initial lesion is accompanied by a peculiar 
edema which keeps the affected region hard and swollen. This edema 
was pointed out by Sigmund as edema indurativum and by Fournier 
as cedeme sclereux. This condition quite often occurs in cases of 
hard chancres of the labia majora, where the affected labium was 
edematous and swollen, and also on the prepuce, causing phimosis, 
and swelling of the whole penis. The skin so swollen is reddish dark 
in color and the borders of the affected skin are usually neatly marked 
off from the healthy skin. The skin so swollen, when examined, 
produces under the exploring finger the sensation of hard strings, 
which are the inflamed lymphatic vessels. Indeed, the infiltration. 



PRIMARY SYPHILIS 



35 



which forms the body of the chancre or of the initial papule, although 
seemingly circumscribed within a focus, has a tendency to spread 
through the lymphatics. It is an every-day observation to find under 
palpation a few days after the appearance of the syphilitic chancre 
on the penis, hard, sluggish, but tender knotty cords from the thickness 
of a thread to that of a string, as the affection of the lymphatics, which 
run towards the lymph glands. 

The infiltration is but the result of the vital reaction of the cells 
opposing the invading virulent germs, and it can be considered as 
any other inflammatory process. The progress of the infection takes 
place through the lymphatic paths, and in the lymphatics is noted 
the presence of the virus. The virus seems to possess an agglu- 
tinating power on the serum, and the leucocytes easily stick to the 
endothelial lining, so that the lymphatics are at times plugged up with 
lymphatic thrombi. This condition of the lymphatic vessels on the 
dorsum penis was first described by Basserau, and has recently been 
studied by Xobl 3 and Neumann, 4 who have attributed the induration 
entirely to the specific alteration of the tunics of the lymph vessels. 
In fact, they are much enlarged and they show rings of infiltrating 
cells, in their endothelium the elements are multiplied and their 
spaces are studded with polynuclear leucocytes. Abundant infiltration 
is found also in the tissues surrounding these vessels. The endo- 
lymphangitis is the cause of more or less complete obstruction of the 
lymph vessels. Their endothelial lining in some instances has gained 
the centre of the vessel, which is not entirely obstructed. 

The connective tissue layers forming the external tunics of the 
lymphatics are involved in the inflammatory process, and are thickened 
by infiltration of cells, which also extends to the surrounding tissues 
in the form of perilymphangitis. The connective tissue fibers are 
also enlarged on account of the irritation and their hyperplastic con- 
dition shows a proliferating tendency. 

The indurated edema is caused by the infiltration and obstruc- 
tion of the lymphatic vessels, which prevents the progress of the 
lymph in the lymphatic spaces. The syphilitic virus contained in 
the lymph vessels causes the cell migration through chemotaxis. The 
small lymphatics remain filled up with a large quantity of mononuclear 
lymphocytes. 

The edema usually remains limited to the labium, or to the 
prepuce, so that it but rarely reaches the mons veneris or the scrotum. 
There is only a tenderness, but no sensitiveness, and in a very few 

3 Nobl, G. " Etiologie et Anatomie pathologique des Lymphangites." 
Comptes Rend., p. 445. 

4 Neumann, I. " Specielle Pathologie und Therapie, herausgegeben von 
Nothnagel." Wien, 1896. 



36 THE MEDICAL ASPECTS 

cases it may wind up with suppuration in some limited portion. It 
continues for a long time, but under treatment gradually disappears 
without leaving any traces. 

The process of the specific inflammation which we have seen in 
the lymph vessels passes to the lymph glands, which soon show 
specific alterations. They are rapidly affected by the syphilitic in- 
fection, and from their development, and from the intensity of the 
infection, an idea of the degree of the virulence of the disease can 
be obtained. The process which affects the lymph glands, producing 
the syphilitic bubo, is entirely different from that of the venereal 
bubo. It consists of a slow inflammatory process of the follicle of the 
gland, with proliferation of the connective tissues, causing a hindrance 
to the normal flowing of the lymph, and an enormous production of 
small young leucocytes, which fill up the alveoli of the glands. In 
the first or second week after the appearance of the chancre, the 
nearest lymphatic glands become enlarged and at the same time show 
some tenderness. This tenderness after some days disappears. Some- 
times it is one, usually it is several glands which are affected and 
enlarged to the size of a hazel-nut or that of a plum, remaining in 
that condition for months. When the chancre has its seat on the 
genitals, the first affected glands are those of the groins, and accord- 
ing to the side occupied by the chancre and to the anastomoses of 
the lymph vessels, they are more on one side than on the other. In 
the case of an extragenital chancre, the lymphatic glands near the 
lesion are first affected ; for a chancre on a finger the epitroclear gland ; 
for a chancre on the nipple, the axillary glands ; for a chancre on the 
tongue, the sublingual glands will be first enlarged and swollen. In 
the case of a patient acquiring both a genital and extragenital initial 
lesion Lang has found not only the glands of the groin, but also those 
of the extra-genital region enlarged. In the groin, although three or 
four glands are affected, one is much more felt, corresponding to the 
initial lesion. Usually they are only tender and for this reason the 
affection is called an indolent bubo; but there are cases ending with 
suppuration. This occurs only as a complication when other injurious 
germs are acting together with those of syphilis. Consequently when 
the initial lesion is ulcerated, and is not kept clean, or when together 
with syphilitic chancre, the virus of a chancroid has been inoculated 
at the same time, we find that the syphilitic bubo ends in suppuration. 
We believe that the syphilitic bubo, when suppurating, can be dis- 
tinguished from the ordinary bubo of the chancroid. The latter is 
greatly inflamed, swollen, and soon fluctuates, while the former has a 
sluggish course, slowly suppurates, and the pus comes from the inter- 
glandular spaces, producing sinuses between the glands. For this 



PRIMARY SYPHILIS 



37 



reason in the treatment of a suppurated bubo, we find it necessary 
to remove all the enlarged glands. The adenopathy in the evolution 
of syphilis follows the chancre, accompanies the mucous patches, and 
the superficial ulcerative lesions, but is independent of them, and is 
the result of the progressing disease. 

In the tertiary period the lymph glands are no longer enlarged, 
they have shrunk, but are still hardened like kernels, this condition 
being due to the sclerotic condition of the connective tissues forming 
their stroma. 

The extended chain of the lymphatic glands represents the bar- 
riers placed to keep virulent germs carried by the lymphatic vessels 
from entering the system. Their swelling and their inflammatory reac- 
tion represents the struggle between the leucocytes and the germs, 
or better the defense of the normal tissues against the invading micro- 
organisms. However, in the syphilitic glands the struggle is rather 
unequal ; the leucocytes are unable to cope with the virulent germs, 
the germs conquer, and the young leucocytes, destitute of any phago- 
cytic properties, increased in quantity in the alveoli of the gland, serve 
as a culture medium for the development of the virulent germs. 

Jullien 5 maintains the same views in regard to the lymphatic 
glands. He believes that the inflammatory process of the glands is 
followed by inertness and impotency; the resources of the organ are 
exhausted, the rushing of the polynuclear cells either impeded or 
insufficient, and in this way they become a kind of hiding place for the 
virulent germs. The same glands, offering a propitious culture medium 
to the germs for their development, also become a place adapted to 
their preservation during the period of latency, confirming the asser- 
tion of Virchow, that syphilitic germs are not preserved in the blood, 
but in the depth of the lymphatic system. 

5 Jullien, L. " Sur le role des ganglions lymphatiques dans les diatheses 
tuberculeuses et Syphilitiques." Bui. et Mem. de la Societe, 1900. 



V 

CONSTITUTIONAL SYPHILIS 

In the preceding chapter we have already expressed our opinion, 
that the initial lesion is a purely local process. It is a place of elabora- 
tion of the virus from which general infection will take place. Yet 
there are some syphilologists who still believe that soon after the 
entrance of the virus into the abrasion an alteration of the general 
system takes place, and that the initial lesion which is formed at the 
point of entrance of the virus is a symptom of constitutional syphilis. 
It was difficult to demonstrate the correctness of our opinion, so long 
as the syphilitic germ and its biochemical functions were not known. 
But from the recent studies on the spirochaetae, and in the resulting 
pathologic alterations in the infected, we may assert that the virus 
produces a cellular infiltration at the point where it has been inoculated, 
and forms the so-called initial sclerosis. For some time the virus 
remains enclosed in the tissue cells, but it is finally carried along by 
the lymphatics and by the blood vessels. , The same cells, which for 
a time have acted as a barrier, begin to migrate and carry the virus 
into other parts of the organism. The ordinary way of spreading the 
infection is by the lymphatics, as already pointed out, and by this 
way the virus enters the general circulation after a certain period of 
quiescence. It is also possible that it may enter the blood current by 
the way of the blood vessels, which is not usually the case ; but this 
explains the occurrence of some cases, where a rapid spreading of the 
infection is noted. Another form of extension, noted especially by 
Lang, is through the interstices of the tissues and shows thick super- 
ficial syphilitic lesions spreading around the initial lesion, and from 
the time and place they appear as a regional infection. We have had 
occasion to notice this peculiar regional infection in the. case of a 
chancre of the nipple, where the whole mamma was, before any other 
general eruption, covered with thick small papules coalescent in 
groups. In this way the virus of syphilis, before the disease becomes 
constitutional, can reach localities not only by the lymph channels, 
but also by regional migration. 

From the post-initial infection (when an individual already having 
a chancre is inoculated at a distance with another chancre), we can 

38 



CONSTITUTIONAL SYPHILIS 39 

conclude that this person was not yet constitutionally infected. In 
fact, a person after being inoculated, having a hard chancre, and an 
involvement of the neighboring lymphatic glands, has not yet the 
constitutional infection of syphilis. The constitutional effects of 
syphilis appear at the moment when the virus or its toxins reach the 
blood in the general circulation and it is carried to every organ and 
tissue of the body. The blood is the first to show a decided effect 
produced by the syphilitic virus in a form of leucocytosis. Stoukoven- 
koff, Biegaski and d'Amore were able to prove that under the influence 
of the syphilitic poison there occurs a rapid decrease of hemoglobin and 
also of the number of red blood corpuscles, with an increase in the white 
blood elements, especially of the lymphocytes. Ernest Becker x made 
the object of his studies the morphological condition of the blood in 
syphilis so as to determine the quantity of erythrocytes and leucocytes. 
In two cases with roseola and marked adenopathy he found a well- 
pronounced leucocytosis, with a predominance of the lymphocytes. 
The relation of the polynuclear to the lymphocytes was 65 : 30, rep- 
resenting in a cubic millimeter 3000 lymphocytes instead of the normal 
1200 to 1500. These observations confirm the views of Virchow, 
that in syphilis the general swelling of the glands goes with the 
lymphocytosis. In a patient affected with the initial sclerosis, without 
constitutional symptoms, the blood was found in a normal condition. 
We have already expressed our opinion 2 that the alterations of 
the lymphatic glands are the causes of the leucocytosis in syphilis. 
The hypertrophy of the connective tissues, which fprm the follicle 
of the gland, together with the altered condition of the tunics of the 
blood vessels, prevents a greater elaboration of the white elements of 
the blood, which in large numbers remain accumulated in the alveoli 
of the glands as mononuclear lymphocytes. This accumulation of 
lymphocytes in the cavitary system of the gland is not the result of an 
active exudation but rather of a passive exudation, caused by the 
difficulty which the lymphatic elements find in going through the 
affected glandular tissue. The enlargement of the lymphatic glands 
at this period of syphilis has been considered as an argument of 
prognosis for the consequent manifestations of the disease. Auga- 
gneur 3 advanced the theory that the lymphatic glands when active in 
their functions, by their phagocytic power must modify the infectious 
elements, and, as a consequence, an intense adenopathy would be a 

1 Becker, E. " Haematologische Untersuchungen." Deutsch. Med. Woch. } 
1900. 35. 

2 Ravogli, A. " A few notes on syphilitic bubo." The Medical News, New- 
York, July 26, 1902. 

3 Augagneur. " Seance de la Societe Franchise de Syphilographie et Dermat- 
ologie," Feb., 189s. 



40 THE MEDICAL ASPECTS 

favorable symptom in syphilis, showing the defensive power of the 
organism. Although this assertion seems quite reasonable theoretically, 
yet it is entirely against the ordinary clinical experience. T. De 
Amicis 4 stated that a great enlargement of the lymphatic glands 
usually accompanies severe cases of syphilis. Mild cases of syphilis 
show mild adenopathy, so that sometimes the diagnosis remains in 
doubt if other symptoms do not show the presence of syphilis. In 
these cases we find that the phagocytic power of the lymphatic glands 
is no longer of any value against the syphilitic infection. 

At the end of this period, which is also called second incubation, 
some patients begin to complain of various disturbances in the form 
of rheumatic pains, especially in the extremities, malaise, no ambi- 
tion, disturbed sleep, dull headache, etc. It seems that the virus already 
circulating in the blood is capable of causing irritation in the tissues, 
and with its toxins acts as an irritant on the central nervous system. 
Not rarely do we see attacks of convulsions in delicate neurotic girls 
precede the eruptions of syphilis. In some cases, however, the syph- 
ilitic eruption is ushered in without any prodromes, and the patient 
does not notice the roseola unless the physician calls his attention 
to it. 

We .have already spoken of a syphilitic fever, which is the fever 
of invasion, resembling that of the contagious exanthemata, the result 
of the spirochaetae and their toxins circulating in the blood. It is 
possible that the virus enters into the general circulation in some cases 
in a large quantity, producing a general febrile reaction, in other cases 
in small quantities and at successive times, so that the general system 
is not greatly affected. 

Fever, when present, has a peculiar type of intermittence, which 
has quite often prompted physicians, ignorant of the existence of the 
chancre, to consider it as malarial fever, and treat it with quinine. 
When studied carefully with the thermometer, it usually shows a 
remittent character. Usually syphilitic fever is not accompanied by a 
chill, but comes in with a headache, general depression, weakness of 
the knees, rheumatoid pains, loss of appetite, sometimes vague neuralgic 
pains. These subjective symptoms are somewhat more aggravated 
towards night, and then the temperature rises to 103 or 104 F., with 
remission towards morning, the temperature nearly reaching the 
normal. The fever lasts from three to four days, and at this time the 
cutaneous surface shows a diffused bluish discoloration, noticeable when 
the patient is divested of his clothes. This condition has been called 
cutis variegata. 

4 De Amicis, T. " Sul preteso potere difensivo fagocitico," etc. Giorn. 
Intern, delle Scienze Mediche. Anno XXIII. 



CONSTITUTIONAL SYPHILIS 41 



SYPHILITIC AFFECTIONS OF THE SKIN 

The eruption is soon replaced by the true erythematous eruption, 
roseola, or macular syphilide, which is the earliest and the mildest of 
all the cutaneous manifestations. It is the first visible proof of the 
general contamination of the system, and, in cases of doubt, is the 
confirmation of the diagnosis. In some cases it is very mild and 
presents only a few lesions, while in others the spots are thick and 
apparent. 

The eruption consists of rounded hyperemic spots, usually with 
ill-defined borders, seldom raised above the level of the normal skin, 
and then but slightly. The roseola spots vary in size from that of a 
lentil to that of a finger tip. Their redness is vivid only in the early 
period, showing a bright pink-rose-red, which does not entirely dis- 
appear under pressure, and leaves a yellowish skin. After some days 
trie spots assume a dark dirty brownish color and remain for some 
time in this condition. The roseolar spots are distributed over the 
body, but not always in the same way. The trunk is most usually so 
affected, so that chest and abdomen are the first regions to show their 
presence, then the upper portion of the extremities and the neck. The 
eruption is more pronounced on the flexor surface of the limbs than 
on the extensor. The palms of the hands and the soles of the feet are 
often the seat of the eruption, but their dorsal surface is usually 
spared. The scalp shows spots of roseola, the face is usually spared, 
only in rare instances is it affected. In some cases roseola occupies by 
preference the anterior, in others the posterior half of the body. In 
one of our cases, after having removed all the affected inguinal glands, 
a few spots of roseola appeared on the lumbar and on the gluteal 
region only. 

Roseola is accompanied by an erythematous affection of the mucous 
membranes of the throat, which is a good characteristic symptom on 
which to base a differential diagnosis from other eruptions of an 
erythematous character. Roseola is the first objective symptom of 
constitutional syphilis, it causes the least marked changes on the skin, 
and it represents the first stage of other efflorescences. In fact, the 
pathological lesions of syphilitic roseola are made up by an increase 
of cells around the capillaries and in the lymphatic spaces. The blood 
vessels show important changes in their tunics, consisting in an infiltra- 
tion of cells and in a proliferation of their adventitial elements. Some 
exudation is also found around the hair follicles, sebaceous glands and 
sweat glands. When roseola is left to itself it persists for some time. 
and its brierht color remains for nearlv two weeks. Then the infiltra- 



42 . THE MEDICAL ASPECTS 

lion gradually diminishes, its color assumes a dirty yellowish or a 
dirty grayish hue, and disappears leaving in some places a mild pig- 
mentation. 

In the regions of the skin which contain a great quantity of 
sebaceous follicles, there sometimes appears a peculiar seborrhea ac- 
companying the roseola. This peculiar seborrheic condition is re- 
vealed by a yellowish dirty brown color of the skin which is dry 
and scaly especially around the nose and mouth, in the naso-labial 
fold, the hairy scalp, along the borders of the forehead and neck and 
sometimes around the genitals. 

The hair begins to get loose on account of an increased quantity 
of the epidermic elements in the follicle of the hair and to fall off in 
spots corresponding to the roseola lesions, producing that character- 
istic alopecia which has been called diradaris. Alopecia is usually 
noticed on the scalp, but not infrequently the hair of the eyebrows, 
axillae, pubis, etc., also fall out in the same way. 

Roseola may form the only eruption of the whole evolution of 
syphilis, and in this case syphilis may show its activity in successive 
eruptions in the form of recurrent roseola. Usually the spots of the 
recurrent roseola are much larger, livid, and somewhat more deeply 
infiltrated, seated on the shoulders, on the chest, or on the abdomen, 
more often on the anterior or posterior folds of the axillae. When 
those patches are reabsorbed in their center, the edges remain some- 
what more prominent and form circular lesions, which have been 
described under the term of roseola annularis, gyrata, figurata, etc. 

We will not dwell on the differential diagnosis of the syphilitic 
lesions, because it is our sole purpose to give an idea of the evolution 
of syphilis in the infected rather than to teach syphilology, and so 
we will proceed to consider briefly the other eruptions. 

Papular syphilide is the next eruption, which in some rare in- 
stances is formed by the roseola spots, which on account of an increased 
infiltration assume the papular shape. In other instances papules begin 
to be mixed among the roseola spots, forming that mixed eruption 
which we call maculo-papular syphilide. Usually after the macular 
eruption has disappeared there is a short period of quiescence, which 
is followed by this eruption. In this case the eruption may be preceded 
by some reactive feverish attack, and two or three days later hyperemic 
spots, brownish red in color, from a pin-head to a lentil in size, make 
their appearance all over the body. The papules in some localities lie 
very close together, in others they are discrete and only a few in 
number. W r e can say that the papule is the true eruption of syphilis, 
which represents an infiltration arising from the connective tissues, 
and especially from the walls of the vessels. In this stage of syphilis 



Plate II 




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CONSTITUTIONAL SYPHILIS 43 

the vessels are affected with inflammation and the arteries, affected 
with a true angitis, cause edema and infiltration of small leucocytes 
into its limited district, which was called by Renaut 5 cone arterielle. 
• The infiltration affects not only the papillary layer but the deeper layers 
of the cutis. In some cases the infiltration forming the papules is 
found more dense around the hair follicles and the sweat glands. The 
infiltration also penetrates into the mucous layer of the epidermis, 
which is the initial step to the breaking down process of the larger 
papules. 

The color of the papules is red only during the first days, for it is 
soon changed into a mixed shade of dark blue or dark brown. The 
papules consist of a circumscribed nodular elevation, firm and solid to 
the touch, varying in size from that of a pin-head to that of a lentil, 
or even greater than a quarter of a dollar. The anatomical region of 
the skin has great influence on the appearance of the papule, which 
takes on different characters according to whether it is situated in a 
dry region or in a place where it is constantly macerated by the perspira- 
tion or by physiological secretions. On the trunk, in the extensor 
surface. of the extremities, the papules usually do not grow much, are 
slightly scaly and remain dry ; upon the hairy scalp they appear scabby, 
and where the skin is in folds the papules are moist, the desquamation 
is replaced by viscid secretion and the papules take on an exuberant 
development. On the palms and soles where the epidermis is thick 
and hard, they assume a peculiar scaly form, which has given origin 
to the misnomer of psoriasis palmaris and plantaris. 

When a dry papule begins to undergo the process of retrogression, 
the red color and the infiltration disappear and desquamation takes 
place, and the papule totally disappears. When the hyperemia and the 
infiltration have lasted for some time, then on the place of the papula 
there remains a reddish brown or a grayish discoloration, which is 
due to a pigment, the result of the effused coloring matter of the 
blood in the meshes of the tissues. This pigment after a while is also 
reabsorbed and, disappearing, leaves the stratum Malpighi also des- 
titute of the normal pigment, forming, especially in a delicate skin, 
light spots which are designated as leucoderma. 

From the size of the papules the eruption has been divided into 
several varieties, as, small and large papular syphilide, or miliary 
papular syphilide and lenticular papular syphilide. Usually the larger 
papules present themselves as such of a large size already formed : 
sometimes they are the result of small papules increasing in size, at 
•times also they are developed from roseola spots. 

5 Renaut, J. " Snr la caraateristique anatomo-pathologique de la syphilis." 
Revue Pratique dcs maladies cutances. Janvier, 1903. 



44 THE MEDICAL ASPECTS 

The eruption has a rather benign course, and in a few weeks a 
lenticular papular eruption is under involution and disappears. It 
lasts for months when it is left to itself without regular treatment. 

In some cases the papular eruption consists of large papules from 
the size of a bean to that of a quarter of a dollar, of a dark reddish 
color like that of boiled ham, or the crust of bread, few in number, 
scattered irregularly on the body. They usually make their appearance 
on the forehead, on the hairy scalp, on the body and extremities. From 
their size they are called giant papules, and an eruption of this kind, 
especially in the beginning of the constitutional eruption, is always 
considered of unfavorable prognosis for the later evolution of syphilis. 

The small papular syphilide or miliary syphilide is also a stubborn 
eruption, and it is usually a sign of a deep syphilitic infection which 
will show up after a while with severe symptoms. In this form the 
papules are small and scarcely reach the size of a millet seed ; they are 
of a dirty brownish red color, aggregated in groups, covering large 
portions of the trunk and extremities. This eruption persists much 
longer than the ordinary lenticular papular syphilide, and in one pa- 
tient six months after the appearance of this eruption it could still 
be seen on his body. The lesions of this eruption are deeply seated, 
and after they are involved and reabsorbed there remain small super- 
ficial atrophic points in the skin. It is not one of the first eruptions 
of syphilis. It sometimes makes its appearance after the roseola, but 
is oftener one of the recurrent eruptions, and is accompanied by a few 
scattered large papules. This miliary papular eruption is constantly 
accompanied by severe syphilitic symptoms on the mucous membranes, 
and the general condition of the patient is run down, with a marked 
pallor and defective nutrition. 

It occurs, and not very rarely, that either on account of the acute 
invasion of the papular eruption or on account of an abundant exuda- 
tion, the papules are surmounted by vesicles. This has been called 
vesicular syphilide, and, on account of its likeness to varicella, has 
been called syphilis varicellaformis. These cases, at the time of a 
smallpox epidemic, are likely to give us trouble with the city authori- 
ties or with the hospital officers, on account of their resemblance to 
variola. 

The vesicles soon dry up and are converted into crusts, which are 
more frequent on the hairy scalp, the face and the legs, in that form 
of syphilis called papulo-crustacea. The possibility of mistake in the 
diagnosis of variola is only for a short time, because by a careful 
study of the development and disposition of the papules, and of the 
accompanying symptoms on the mucous membranes, the error will 
soon be dispelled. 



CONSTITUTIONAL SYPHILIS 45 

On account of the thick epidermis on the palms of the hands and 
on the soles of the feet, the syphilitic papules of these regions are not 
raised up, but are flat, with a very slight elevation: They soon begin 
to desquamate, and are covered by dense epidermis in the form of 
white adherent scales, which are partially detached and replaced by 
new scales, the desquamation being formed by old and new scales. 
This form of syphilitic papules have a tendency to frequent recurrence. 
Their appearance is usually at an advanced stage of syphilitic evolution, 
and they are quite obstinate under the best treatment. 

The papules of the palms and soles appear at first in the form of 
reddish circumscribed spots from the size of a pea to that of a finger- 
nail in the center of the palms and extend in a circular manner towards 
the periphery. After they have remained some time covered with 
scales, the central scales are lost, and the papule remains as a large 
patch of a bright red color, smooth in the center and surrounded by 
a border of scaly, hard epidermis. The patches sometimes coalesce 
and extend in a serpiginous way, involving the whole palm, with an 
active thick desquamation. In case of deep infiltration the skin is 
apt to crack and form fissures, which cause a great deal of pain and 
inconvenience. The chronicity of the syphilide in this region is mostly 
due to the fact that the lesions are constantly exposed to friction and 
to pressure, causing a continuous irritation. On the soles of the feet, 
although the eruption has the same character, yet it is not so stubborn 
as on the hands, as it is somewhat more protected from external 
injuries. 

Papules also afTect the fingers on their flexor surfaces, and the 
toes, on the concave portion of the plantar region, being subject to 
motion, easily crack and form painful fissures. The nails are affected 
by papules either around the fold containing the nail, or inside in the 
nail bed : in the first case they appear like a flat reddish papule covered 
with a thin desquamation ; in the second under the nail, like a round, 
yellow, brownish spot, raising the nail somewhat. The nails become 
dull, fissured, and scaly. 

It is worthy to be mentioned that a papular infiltration at the 
edge of the heel or on the plantar surface of the foot, on the ball of 
the big toe, in the places where there is thick epidermis and it is ex- 
posed to continuous pressure, sometimes assumes quite peculiar char- 
acters. The skin covered with a papule shows a round area of nearly 
half an inch in the form of a callus. On account of maceration from 
perspiration, the epidermis is lost in the center and the papular infiltra- 
tion covered with a thick epidermis remains at the periphery, giving 
the appearance of a crater. The crater begins to ooze and forms an 
ulcer which resembles the perforating ulcer and has no tendency to 



46 THE MEDICAL ASPECTS 

heal up on. account of its callous borders. Similar ulcers are often 
seen on the hands of patients who had thick callous formations in 
these regions. . 

Papules situated in an anatomical region- exposed to continuous 
moisture change their appearance so much that they have been dis^ 
tinguished by some authors from the ordinary papules -and have been 
considered as the characteristic eruption of syphilis. Under the name 
of plaques muquciises, tubercules muqueux, moist papules, papulae 
Jutmidcc are considered papular efflorescences, which being constantly 
wet with perspiration, urine, or other secretions, become quickly 
macerated, denuded of their epithelium, and show a moist surface. 
They are usually found on the external genitals, in the genito-crural 
fold, in the perineum, around the anus, the depression- of the navel, 
under the breast of woman, under the axillae, in the spaces between 
the toes, in the' auditory canal, the angle of the mouth, and in any 
place soiled by urine or feces, especially in children who are not kept 
scrupulously clean. In some cases the mucous patches form all the 
syphilitic symptoms, by their persistent relapsing. 

The moisture of the place, and warmth, seem to favor the develop- 
ment of the moist papules, so that when an ordinary dry papule has 
reached the size of a millet-seed, and does not exceed that of a split- 
pea, the moist papule attains the size of a ten-cent piece and even 
greater. It begins as a flattened elevation, round or discoid in form, 
and from this appearance it has also been called flat or condylomata 
lata. The larger patches present a depression in the center and the 
edges are somewhat elevated over the normal level. They are usually 
grayish red in color, succulent and soft, and, after some time, take on 
a dark bluish color. The epidermal covering macerated by the 
moisture becomes grayish, and is easily rubbed off as a pellicle, leaving 
a flesh raw patch oozing abundant serum which causes a nauseous odor, 
hence the name of pustula fcetida, of the old authors. The irritation 
of this secretion, together with the saline reaction of the perspiration, 
produce an irritation on the papillae, which rise in points above, the 
whitish pellicles of the macerated epithelium, which gives to the lesion 
an appearance similar to a raspberry. 

The same condition of moisture, warmth and dirt, with the con- 
tinuous irritation, and probably through a local infection, cause the 
patches' to multiply to such an extent around the labia majora, the 
anus and their vicinity, that these parts are densely covered by them 
and almost no normal skin left between them. The papules surround- 
ing the anus look like red, swollen folds entering the anal orifice and 
are seen as ulcerated patches by distending the sphincter. 

In fact, when the papules remain moist they break down, causing 



Plate III 





Papulosquamous Syphilide Four Years After Infection 



CONSTITUTIONAL SYPHILIS 



47 



a loss of substance. In this way they become ulcerated and the ulcer 
may extend deeper and replace the papule entirely in its extension. 
The ulcer usually clears up and cicatrization begins, leaving a super- 
ficial scar. 

Mucous patches frequently recur, and they are present when all 
other symptoms have disappeared. They are the most dangerous lesions 
for spreading the contagion to well people who are brought into con- 
tact with a syphilitic individual. It is one of the most persistent 
lesions. It is often a relapsing lesion, which is usually seen during 
the first two years after the infection, but they are sometimes found 
after four and five years. 

In regard to the eruptions of papular syphilides there is to be 
noted that the early eruption has a tendency to spread all over the 
body in a symmetrical disposition ; but later on in their successive 
recurrences the number of papules is limited to a few scattered irregu- 
larly on one region of the body. 

In this case the papules have no longer a symmetrical disposition ; 
they are grouped together and often arranged in a circular or in a 
semicircular form. In a patch formed by syphilitic papules we see 
in the middle old papules in the way of involution ; some partially 
healed up, others covered with scales and the new papules along the 
periphery showing the peripherical growth of the syphilitic lesions. 
The dry papules produce no subjective symptoms in the patient, only 
at the time of desquamation do they cause itching sensations. 
The moist papules are usually troublesome, being accompanied by an 
itching and burning sensation; they cause fissures and ulcerations, 
which are very painful, especially near the anus. On the toes, on the 
palms and soles, the papular eruption may become so painful on 
account of the fissures as to prevent the use of these parts. 

With this eruption there are many other concomitant affections. 
Alopecia, affections of the mucous membranes of the mouth, nose, 
pharynx and larynx, iritis, and general enlargement of the lymphatic 
glands are constantly present. Sometimes neuralgia, paresis and oc- 
casionally symptoms affecting the central nervous system are found 
along with this eruption. It is also found in association with syphilitic 
inflammation of the periosteum, of the joints, of the muscles, of the 
tendons, of the synovial sacs, and it is not out of the range of possi- 
bility to find it accompanied by a gummatous infiltration of the skin 
or of some other organ. 

It is very easy to establish the diagnosis of papular syphilide by 
the form of the eruption, its location and distribution, the accompany- 
ing symptoms, and much more so when we are able to demonstrate 
the presence of the initial lesion or its scar. But there are some cases 



48 THE MEDICAL ASPECTS 

where the diagnosis is quite difficult on account of possible confusion 
with similar eruptions. At the period of desquamation, in cases where 
the papular eruption has lasted a long time, it may be confused with 
psoriasis vulgaris, or also with tinea tonsurans of the body. This error, 
however, can be easily avoided by a careful study of the symptoms 
already mentioned above. Lichen planus may offer some points of 
similarity to a papular syphilide and much more on account of the 
tendency of lichen planus to attack the mucous membrane of the 
mouth and tongue. But the study of the lesions of lichen, their waxy, 
shining papules with a central depression, their tendency to arrange 
themselves in groups, the long standing of the papules, the intense 
itching accompanying the eruption, are characteristics which are suffi- 
cient to dispel any possible error. 

Mucous patches are so characteristic that when once seen there 
is no possibility of mistake, and indeed in some doubtful cases, the 
appearance of one of these papules is sufficient to confirm the diagnosis 
of syphilis. 

After a papular eruption has left the skin, some pigmentation 
remains on the places of the papules in the form of pigment spots, 
which give to the skin a marbled appearance. This peculiar 
form of pigmentation has been considered by some authors as an 
independent syphilitic eruption, which has been called syphilis pigmen- 
taria. But the careful study of the patients has shown that the remain- 
ing pigmentation is the result of the syphilitic lesions which have been 
on the skin, and according to all appearances the pigment spots are 
connected with the antecedent eruption. It is in the form of spots at 
times of the size of a lentil or of a ten-cent piece, 'at times larger, 
where the pigment had diminished or has entirely disappeared. These 
white spots make a distinct contrast to the normal skin which, retaining 
its pigment, is seen in the form of darker stripes. This discoloration 
has been very properly called syphilitic leucoderma. It appears more 
frequently in women and it is more apparent on the neck, although 
it can be seen on the upper portion of the chest, on the trunk and 
on the extremities. After the involution of the first macular or papular 
eruptions of syphilis on the regions named, there remain small round 
or oval whitish spots, which touch each other. The normal skin 
appears more deeply pigmented, and the whole looks as if the neck 
had not been washed. The leucoderma disappears very slowly, dimin- 
ishing gradually in its intensity in the interval of from one to two or 
even four years. The treatment has no influence whatever on its 
involution. 

Although many authors claim that leucoderma is found preferably 
in individuals with dark complexions, we find that on the contrary it 



Plate IV 




ClRCINATE SYPHILIDE OF DIFFUSED T 



VPE 



CONSTITUTIONAL SYPHILIS 49 

is much more frequently found in individuals with white, thin and 
delicate skin and blond hair. In a large number of syphilitic patients 
we have found this leucoderma on the sides of the neck, only excep- 
tionally in men, while in the female ward we find it quite often, in 
its various degrees. 

Syphilitic leucoderma is so characteristic that once seen it cannot 
be mistaken for other discolorations of the skin. It is a sure sign of 
syphilis, although it is not a syphilitic eruption, as Hardy called it 
syphilis pigmentaria. Furthermore, it is a sign of syphilis already 
progressed ; it appears only after the eighth or twelfth month from the 
infection. 

Syphilitic virus by itself is not capable of producing pus, and when 
pus is formed on the syphilitic lesions it is due to the cocci of 
pus, which transform the papule into a pustule. The pus cocci are 
found everywhere, and free on the surface of the skin they enter into 
the syphilitic lesions by artificial cultures, as has been proved by 
Campana 6 and by Lang, 7 who found staphylococci within the tissues 
at a great distance from the border of the pustules. We have already 
seen that, on account of a large quantity of exudation, the apex of the 
papule in some cases is raised in the form of a vesicle, the fluid after 
a while is dried up, leaving a scab surmounting the syphilitic papule. 
When, however, the staphylococci enter into the exudation of the 
vesicle, it becomes purulent, the pus soon dries up into a scab, giving 
place to an impetiginous eruption, which has been called syphilis papu- 
lo-pustulosa, or syphilis papulo-crustosa. 

These pustular eruptions are more frequently found on the hairy 
scalp, on the lower extremities, and not infrequently on the face. If 
we remove the thick dark greenish scab, w r e will find an ulcerated 
surface covered with pus, and when the whole papule has suppurated, 
the ulcer begins to granulate, showing a raw surface, which after it 
has healed up leaves a superficial cicatrix, corresponding to the original 
lesion. 

When a pustular eruption afTects the scalp or the part of the 
face covered with the beard, the follicles of the hair are involved and 
as a consequence the hairs get loose and fall out. Pustular syphilides 
are always found in individuals run down in general health, whose 
nutrition has failed on account of the syphilitic process, and much 
more on account of their systemic conditions and hygienic surround- 
ings. In these cases it happens that the infiltration of the syphilitic 
eruption is turned into suppuration, forming pustules of different 
varieties. 

Syphilitic pustules have characteristics of their own, which dif- 

6 Campana, R. Fra Castorius. 7 Lang, E., 1. c, p. 6S. 



50 THE MEDICAL ASPECTS 

ferentiate them from an ordinary pustule. This latter has an acute 
course, the epidermis is readily raised by pus, is surrounded by an 
inflammatory halo, soon breaks, and the pus is dried, forming a scab 
which drops off leaving a surface covered with new, normal epithelium. 
The syphilitic pustule, on the contrary, has a slow course on account 
of the fact that the infiltration but gradually undergoes suppuration. 
The epithelial covering, which contains the pus, remains for some 
time on account of lack of pressure on the part of the fluid. The first 
quantity of pus is already converted into a dry crust, and the suppura- 
tion continues underneath, so that the crust is pushed somewhat higher 
by the fluid and forms thick, bulky crusts. So long as infiltration 
remains, suppuration continues, and on account of the formation of a 
heavy thick edge around the pustule the process is maintained by the 
renewed infiltration. In this way we must see in a syphilitic pustule 
an ulcerative process, which is not very deep, involving only the upper 
layers of the skin. When the infiltration has disappeared the ulcer 
clears up and the process of reparation takes place, always healing 
with a superficial cicatrix. 

Sometimes the infiltration and suppuration progress on one side 
of the lesion, while the other side is healing. Thus the ulcer takes a 
semilunar appearance. This ulcer progressing in this way is called 
a serpiginous ulcer. The scar which retains this peculiar shape re- 
mains there to indicate the existence of a pustular syphilide. 

In the ulcerated base of a syphilitic pustular lesion papillary 
growths may take place, which, resembling reddened granulations, are 
elevated above the ulcer, oozing purulent matter, partially covered 
with dirty crusts. This condition of the ulcerated, pustular syphilide 
is found especially in the hair and the beard ; it resembles sycosis and 
has been called syphilis framboesioides. 

Pustular syphilides, like papular syphilides, in the early period 
have a tendency to affect a large area and to assume a symmetrical 
distribution. In the late period the lesions are much deeper, are 
isolated and scattered in a few places only of the cutaneous surface. 
The pustular eruption may be preceded by an attack of fever, which 
sometimes continues, according to the quantity of suppuration. From 
the size of the pustules, pustular syphilide has been called syphilis 
varicellaformis, and also acne syphilitica, when it results from small 
pustules distributed with certain regularity, recalling the distribution 
of varicella. When resulting from large pustules scattered on the 
body, it is called syphilitic ecthyma. Very large pustules, the size 
of half a dollar or more, developing slowly, with thick, elevated crusts 
resembling the shell of an oyster, have been called syphilitic rupia, 
from (pi'Tros) which means filth. 



Plate V 




Pigmentation Left by Hemorrhagic Papular Svphilide 



CONSTITUTIONAL SYPHILIS 5 1 

The course of a pustular syphilide is rather long, because it takes 
time for the lesions to heal, and while they are healing new ones are 
coming, prolonging the affection indefinitely. 

In rupia we always find a superficial ulceration of the skin, af- 
fecting a place about the size of a half dollar or larger. It begins 
in the form of a blister, of which the over-lying epidermis is flaccid 
and wrinkled, containing only a moderate quantity of sanious purulent 
fluid, which dries up, forming a dark-brown scab. Under the crust at 
its periphery fresh suppuration takes place, which gradually raises up 
the first crust, forming a second one, which looks like a ring. The 
process of disintegration is repeated and the crust grows on account 
of the new concentric rings formed by the continued suppuration. 

When the crust is removed an ulcer is exposed, oozing a thin 
sanious pus. Its edges are infiltrated, and when the infiltration fades 
the ulcer is repaired. The process of cicatrization takes place first 
in the center of the ulcer and then in the periphery, sometimes showing 
ulcerated rings. The cicatrix is in the begining of a bluish red tint, 
which slowly grows paler until it becomes a brilliant white color. It 
is lower than the level of the normal skin and it appears thin and 
atrophic. 

Syphilitic rupia is found in an advanced stage of syphilis. The 
lesions are sometimes thickly spread on the skin, but are ordinarily 
limited to only a few, and sometimes to only one pustule, which shows 
the existence of constitutional syphilis. 

Before leaving the subject of pustular syphilides, it is worthy to 
mention the resemblance which a small pustular syphilitic eruption 
has to a case of varioloid. We have already said that at the time of a 
smallpox epidemic some of these cases are capable of causing much 
trouble with the health officers. The resemblance is so striking that 
the eruption has been called syphilis varicellaformis, and there are 
some cases where it is rather a difficult task to decide at first glance 
whether we have to do with a case of varioloid or with one of pustular 
syphilide. 

It is stated that the eruptive fever is somewhat more intense in 
smallpox, but we also find fever preceding the syphilitic eruption, and 
sometimes a very mild fever at the beginning of a smallpox case. It 
is very rare that a pustular syphilide is not accompanied by other 
syphilitic lesions, especially on the mucous membranes in form of moist 
papules. Syphilitic pustules have a much slower course and last for 
weeks ; while in smallpox the pustules dry up in a few days, as the 
whole process runs its course in a shorter time. So when we have to 
deal with pustular syphilides, the pustules last for some days : some are 
still in the form of papules when others already show a formed crust. 



52 THE MEDICAL ASPECTS 

This is different from the appearance of smallpox, where the eruptive 
lesions show nearly the same condition. 

Other affections may also be mistaken for pustular syphilide ; such 
as acne varioliformis (Hebra), acne necrotica (Boeck), acne cachecti- 
corum; but the error will easily be dispelled by considering the other 
syphilitic symptoms, which are constantly found present in syphilitic 
diatheses. 

In some cases of deep syphilitic infection papules of a late syphili- 
tic eruption have shown necrotic process. The papule is connected in 
a small dry gangrenous patch, black in color, which gradually is 
detached and is replaced by a scar. 

SYPHILIS OF THE SKIN APPENDAGES 

During the evolution of syphilis the hair is affected in different 
ways, showing that it is not spared by the poison any more than the 
other tissues of the body. Everybody knows that when syphilis breaks 
out the hair begins to fall. The following also constitutes a symptom 
of syphilis ; if, when passing our hand over the head of the patient, we 
close at the same time our fingers, a few hairs remain between them. 

After the first appearance of roseola or somewhat later, the hair 
becomes dry, loses its brilliancy and becomes loose in its follicles. The 
hair falls out in small areas, reminding one of the distribution of roseola 
or papular lesions. When the patient has his hair cut short, the bald 
areas show very prominently, and the scalp looks as if it were eaten 
by moths, alopecia diradans. In some cases the thinning out of the 
hair increases to a total baldness, and it also affects the hair of the 
body, eyebrows, beard, axillae, pubis, etc. With this alopecia there are 
no signs of disease of the scalp, no lesions, no desquamation. 

In the first instance of alopecia the hyperemia and the exudation 
around the follicles of the hair forming the roseolar or the papular 
spot, are accountable for the loosening of the root of the hair from the 
papilla, and for the shedding of the hair. In the second form of 
alopecia, it forms a symptom by itself and is probably due to a tropho- 
neurotic condition induced by the syphilitic toxins. Syphilitic alopecia 
occurs more commonly during the first year of the infection, and 
usually shortly after the first general eruption. The hair is lost mostly 
on the sides of the head, the temporal and occipital regions first show 
the thinning of the hair. In cases where very little treatment has been 
given to the patient, the loss of hair may occur at a later period. 
Syphilitic alopecia is always temporary; it will cease after weeks or 
months and new hair will grow out, but the growth of the new hair will 
not be so luxuriant. Permanent baldness is of but very rare occur- 



Plate VI 




< 

w 

O 

w 
u 




CO 



CONSTITUTIONAL SYPHILIS 53 

rence. It does happen, however, when syphilitic infiltration destroys 
the papillae of the hair or impairs its follicles, and in these cases we 
have a resulting scar which is destitute of hair on account of complete 
destruction. After gummatous ulcers, after pustular extended ulcera- 
tions and sometimes also after deeply seated papules, scars remain 
which are destitute of hair. 

The nails are also affected by syphilis in its different forms. They 
lose their brilliancy, assume a matt color, and easily split and splinter, 
as results of the nutritive changes in the matrix of the nails. These 
alterations of the nails rarely show up alone, for they usually accom- 
pany cases of papulo-squamous syphilides of the palm or soles, or of the 
volar and plantar surface of the fingers and toes. Although the erup- 
tion has disappeared, the altered condition of the nails persists un- 
changed for a long time in that form described by Fournier as onyxis 
craquele. The nails have not only lost their luster and become yellow- 
ish and dull, but are marked by parallel lines or ridges. The edge of 
the nail cracks and breaks easily, leaving ithe edge unequal and 
irregular. This form of onyxis is often associated, or better, is pro- 
duced by a form of dry paronychia. Usually several nails are affected 
at the same time. 

Paronychia has been divided into several types, which can be called 
dry, inflammatory and ulcerative paronychia. The varieties depend 
entirely on the infiltration and the period of the syphilitic affection. It 
may be the result of an initial lesion, of a papule, of a pustule or of a 
gumma, with the resulting change in the severity and nature of the 
paronychia. In paronychia the syphilitic deposit is found in the matrix 
or in the lateral furrows which contain the nail. 

In the case of a superficial papule the paronychia may remain dry ; 
but in the case of an initial lesion, of a pustule or of a gumma suppura- 
tion occurs and this leads to ulceration. The nail in this case is thick- 
ened, infiltrated and ulcerated towards the edges of the ulcerated fur- 
row. On account of the resistance of the tissues, the pathological 
process of syphilitic paronychia is accompanied by pain, which persists 
until the absorption of the infiltration and the healing of the ulceration 
takes place. When the process affects the bed and the matrix of the 
nail this is nece'ssarily lost and the new nail is commonly thick, chalky 
and deformed. In some cases of old syphilis the nail plate assumes a 
form of hypertrophy in length and in volume to resemble a claw, 
which has been called onychogryphosis. 



54 THE MEDICAL ASPECTS 

LATE SYPHILIS OF THE SKIN 

When syphilis has reached the period of maturity, the true 
syphilitic product is the gumma. Unlike the other syphilitic products 
already considered the gumma is subject to disintegration, for although 
it may come to the most favorable end, that of reabsorption, yet signs 
of destruction will remain in the affected places. It forms a more 
serious affection than the other lesions, which are of an irritative and 
resolutive character, and do not imply destruction of the tissues af- 
fected. The process of gummatous infiltration affects the connective 
tissues or their equivalents, bone, skin, etc., through which the elements 
of the tissues, pressed by the interstitial growth, become at first hyper- 
trophic, then atrophic, necrobiotic, and must finally die. According to 
the tissues involved, it sometimes causes intense pains, which increase 
at periods, especially at night, and are described as tearing and boring 
pains ; at other times, when affecting the subcutaneous tissue, the 
patients have cutaneous gummata for a long time, without being kept 
from their occupations. 

Gummata occur in a double form ; some are superficial and others 
are deep. 

The superficial gumma is just the same as that which many authors 
call tubercular syphilide. Indeed, they admit that between the tubercle 
and the gumma there is a striking analogy ; they possess identical 
histological characteristics, the difference is only in the size and depth 
of the infiltration. The syphilitic tubercle is an intradermal lesion, 
while the gumma is extended to the subcutaneous tissues. It is more 
practical to consider all under one nomenclature, gummata, and dis- 
tinguish them as superficial and deep. 

Superficial gummata appear on the skin in the form of roundish 
flat nodules, of a brownish red or copper color, varying from the size 
of a pea to that of a bean, and having their seat in the derma. They 
are sharply defined in the form of small tumors, hard, resistent and 
elastic in the beginning; but softer later on. 

Gummata in general make their appearance only in the later stages 
of syphilis, from three to four years after the infection, and sometimes 
not before the tenth, fifteenth or the twentieth year. ' In exceptional 
cases they may show up earlier, so much earlier, indeed, that they may 
exist along with lesions of secondary nature. Their early occurrence 
always shows a grave and anomalous type of syphilis. Gummata are 
usually found in association with pigmentation, cicatrices, and dis- 
colorations left by former syphilitic eruptions. 

While superficial gummata may develop on any portion of the 
body, yet they are usually limited in number, and have a tendency to 



CONSTITUTIONAL SYPHILIS 55 

affect the face, the back of the shoulders, arms, thighs and legs. They 
are essentially chronic in their course and may undergo reabsorption, 
but in most of the cases they soften and ulcerate. The central portions 
of the gummatous nodules are more often affected, and there the pro- 
cess of disintegration begins, which is very slow and causes the lesion 
to remain for a long time. 

When the syphilitic infiltration forming the gummatous nodule 
undergoes reabsorption, it diminishes and flattens, and the epidermis 
is thrown off in scales. Its bluish color is changed into a rusty brown, 
the center is depressed, and the skin is changed into a whitish atrophic 
scar, which remains surrounded by heavy brownish pigmentation. The 
pigment resulting from the long-standing hyperemia and the effusion 
of the coloring matter of the blood is gradually reabsorbed in the upper 
portions of the body, but on the extremities it remains through life. 

When the superficial gumma breaks down, an ulcer is the result, 
which upon the drying up of the purulent secretion, is soon covered 
with thick heavy crusts, strongly adherent. When the crusts are re- 
moved, a sharply defined ulcer is discovered with a yellowish bottom 
and steep edges, somewhat undermined and involving the whole thick- 
ness of the skin. The ulcer progresses as long as the borders and the 
base remain infiltrated and soiled with detritus. When the infiltration 
diminishes, the bottom of the ulcer clears up and shows the healthy 
granulations, which are soon covered by epithelium, forming a thin 
depressed cicatrix, at first heavily pigmented, then glistening white. 

Superficial cutaneous gummata have a tendency to come in groups, 
covering a large area of the skin. In some cases the nodules are so 
thickly pressed one against another that it is difficult to recognize the 
individual lesions. The skin presents in these patches all the different 
stages of the nodules from the bluish red infiltration to the scaly con- 
dition, and as the older ones have been already reabsorbed in the center 
of the patches, cicatricial portions are also found. 

When the gummata undergo disintegration, ulcers are formed, 
which last for a long time, healing slowly and leaving deep scars. 
When the gummatous infiltration has affected the skin which covers 
the cartilages, or superficial bones, like the auricles, the nose, the eye- 
lids, and the forehead, the ulcer may then denudate these parts and 
cause necrosis, with the resulting destruction of these organs. 

The ulcers usually appear in chains, interrupted by a cicatrix of 
old ulcers already healed up. New nodules arrange themselves around 
the old lesions, forming increasing circles, taking on a serpiginous 
appearance. In the same way ulcers are progressing, healing- towards 
the center, and extending along the periphery. This peculiar way the 
ulcer has of extending gives to it the shape of a kidney or that 



56 THE MEDICAL ASPECTS 

of a sickle, which can be considered as characteristic of the syphilitic 
ulcers. 

The number of gummatous nodules of the skin is sometimes 
limited to a few, but sometimes they are spread over large areas, cover- 
ing one entire shoulder or the whole gluteal region, and lasting for 
years, especially when not properly treated. 

SYPHILITIC AFFECTIONS OF OTHER TISSUES AND ORGANS 

Since the time of Petit 8 the gumma has been considered as a 
collection of fluid, but in reality it consists of a mass of small round 
cells, which are only young mononuclear leucocytes. In the formation 
of a gumma the difference of the tissues affected, their compactness 
and their quantity of blood vessels have a great deal to do with its 
appearance. In every gumma the blood vessels are affected in their 
tunics by an infiltrating process, but the lymph vessels are also en- 
larged, obstructed and inflamed, showing that the formative process 
of granulation has started from them. In the gummata, together with 
the infiltration, there is also a proliferation of the connective tissues. 
In some gummata the infiltration and proliferation of cells is the main 
feature, and in this case the intercellular substance becomes softer, 
semifluid, and the melting mass gradually becomes purulent, breaks 
down, and ends in an ulcer. In the others the proliferation of cells 
remains circumscribed, the intercellular substance multiplies, their cells 
maintain their form, or assume a round shape, like that of the granula- 
tion cells, undergoing in their way a fatty degeneration. In the first 
case the process resembles a heteroplastic change, while in the second 
it is more like the hyperplastic alterations leading to a sclerosis. 

The difference between the cutaneous and the subcutaneous gum- 
mata consists mostly in the size ; in the latter the morbid product forms 
nodules of considerable volume. Tumors from the ordinary size of a 
bean or walnut may attain that of the fist, and even greater, in the 
form of a tumor, round, oblong, or flattened in shape, originally of 
firm consistency, and movable under the skin, or else fixed to the 
underlying fascia, according to whether they originate in the loose con- 
nective subcutaneous tissue or in that of the fascia. The skin covering 
a gumma has at first the same color and a normal aspect, but gradually, 
as the gumma increases in size, it is subject to important changes. On 
account of the distention produced by the growing tumor, the skin 
becomes whiter and glistening and, on account of the difficulty of cir- 
culation, shows an edematous swelling. The gumma remains for a 
long time in this condition, until it becomes softer in the center, and 
after a while in the periphery also, giving to the examining finger the 
sensation of a soft, elastic and fluctuating mass. 

8 Petit, Louis. "Traite des maladies des os." Paris, 1735- 



Plate VII 




Papular Syphilide with Gangrenous Spots 



CONSTITUTIONAL SYPHILIS 57 

If an incision is practiced on the gumma at this period, no pus 
will be found, only a small quantity of a sticky viscid fluid, resembling 
a solution of gum arabic, with a few pus corpuscles and a few drops 
of blood. From the presence of the mucilaginous fluid the tumors 
have been called gummata. 

The end of the gumma varies quite a great deal. In some for- 
tunate cases, after the infiltration has undergone fatty degeneration, 
the newly formed particles of tissues are changed into a granular 
detritus, which is gradually absorbed. The skin over the site of the 
original gumma remains depressed, thin, but not materially changed, 
though with some abnormal pigmentation. 

In other cases when the process has advanced so far that the skin 
covering the gumma has become bluish red, threatening to break down. 
the absorption of the deep-seated parts of the gumma is still possible. 
Then the bluish tint of the skin is changed into a faint red, remaining 
somewhat edematous. Gradually as the absorption takes place, the 
edema disappears and the gumma appears depressed, and is re j 
absorbed, leaving an atrophic scar to mark its seat. When the absorp- 
tion disposes of but a part of the contents of the gumma, those remain- 
ing undergo cheesy degeneration, which through irritation produces 
suppuration and is thus finally emptied and removed. In other cases 
the fluid part may be absorbed and the solid changed by calcareous 
degeneration into a hard mass, which, encapsuled by connective tissues, 
remains as a dead product of the process. 

The usual issue of the gumma is the ulcer. The skin covering the 
tumor becomes bluish red, infiltrated, edematous, and attached to the 
whole mass ; it becomes thinner and is perforated at the highest point 
of the tumor. A quantity of purulent matter, together with necrosed 
parts of the gumma are emptied, and an ulcer remains. It will extend 
according to the infiltration of its bottom and edges. The edges appear 
bluish red, thickened, neatly cut, undermined, while the bottom has 
a yellowish cover, due to the necrotic shreds and detritus, infiltrated 
without any tendency to granulations. 

The purulent secretion is usually rather thin, and abundant in 
accordance with the disintegration of the infiltration. When the in- 
filtration has been destroyed by suppuration, the ulcer begins to clear 
up, the edges become flat and slope toward the bottom, which begins to 
show red granulations ready to start the cicatricial process. The in- 
filtration of the edges disappears, and they begin to show a whitish line 
of good cicatricial tissue, from which place it extends till it covers 
the whole surface. On account of the irregular destruction of the 
underlying tissues the scar is often nodular and irregular and usually 
surrounded by a brownish pigmentation. 



58 THE MEDICAL ASPECTS 

In some cases we may have the healing of the gumma on one side 
while the extension of the infiltrating process is progressing on another 
side, in a serpiginous way. In the deep gummata, however, this oc- 
currence is not so frequent as in the superficial one. 

The subcutaneous gumma usually affects the body one at a time, 
but we may also find several gummata at the same time. It frequently 
occurs on the forehead, neck, shoulders and legs. From the size of a 
hazel-nut, gumma may attain that of a goose egg and even greater, 
especially when seated on the trunk. 

In individuals debilitated, in poor health, or who have had im- 
proper treatment, the infiltrated gumma may undergo rapid disintegra- 
tion, which causes extensive ulcers, producing the destruction of the 
tissues and organs affected. In one of our cases the destruction of 
nearly the whole inferior lip occurred in a few days in a syphilitic in- 
dividual, eight years after the infection. These gummatous ulcera- 
tions, with such quick destructive power are accompanied by unbear- 
able pain, which prevents the sufferer from sleeping. 

In some cases gummata may be so numerous as to produce the 
destruction of the skin in large areas. When reparation is partially 
effected, the cicatrix draws and may cause a contraction of the joints. 
In one case a gumma of the knee joint had taken so large a develop- 
ment after a slight injury as to give the idea of an aneurism. Gum- 
mata, on account of the destruction of the lymphatic vessels, may be 
the cause of stasis of the lymph, which together with the altered con- 
dition of the periosteum and of the fascia, produces an elephantiasic 
condition of the legs, and of the affected organs. 

In some cases the gumma is rapidly converted into a gangrenous 
mass, gangrenous gummata. The change is very rapid and the 
destruction of the organ is the result. In a patient in the hospital, who 
had been admitted for phimosis, upon opening the prepuce the whole 
glans was found to be a gangrenous mass. In the same way gummata 
of the skin have changed in a few days into gangrene, which limited 
itself, sloughed off and healed up in a short time. In some cases when 
blood vessels are taken in by the destructive process, hemorrhage is the 
consequence. 

It sometimes occurs that a carcinomatous growth has found its seat 
on an ulcerated gumma. Hutchinson and Langebeck have referred to 
many cases of carcinoma in conjunction with ulcerated gummata, and 
Lang and Doutrelepont have often found carcinoma connected with 
syphilis. In this case the ulceration from syphilis is the door of en- 
trance for the cancerous germs, and the tissues, flabby and lacking in 
vitality, are a good ground for their development. 

In many cases tuberculosis is also associated with syphilis, and 



CONSTITUTIONAL SYPHILIS 59 

both together cause the most hideous ulcers and extensive destructions. 
Although ulcers of this kind may be found in any place, yet we have 
very frequently met with extensive ulcers of the vulva in syphilitic 
patients who were also affected with tuberculosis. 

Extensive ulcers of the labia majora with a greatly diffused in- 
filtration and surrounding edema, are frequently found in prostitutes. 
The syphilitic infection in all such cases dates back several years. In 
one instance the hard palate was affected with extensive superficial 
ulcerations, which could have been referred to as tubercular. Cases 
of extensive ulcers of the vulva have been described by Huguier 9 and 
others as lupus of the vulva. 

Hyde 10 and Taylor " denied the idea of lupus, and claimed those 
ulcers to be the results of syphilitic infiltration. Taylor especially does 
not mention at all the possibility of tuberculosis acting together with 
syphilis. The existence of both diatheses together, according to our 
experience, cannot be denied, and we can say that when both exist in 
the same individuals one intensifies the other. In another case of a 
colored woman there were symptoms of pulmonary tuberculosis, to- 
gether with a marked syphilitic diathesis, and it was difficult to eliminate 
either one as causes of the destructive condition of the external 
genitals. 

It cannot be denied that the induration from the infiltration, and 
the following chronic edema, may become a cause of ulceration 
through lack of attention, together with chronic vaginal discharge 
and the presence of urine ; but in many cases it seems that the associa- 
tion of tuberculosis with syphilis is more plausible. 

This ulcerative process, associated with an infiltrated condition of 
all tissues, becomes so extensive and so destructive that it gradually 
removes large portions of skin and of the underlying tissues, sometimes 
lasting for years, until death relieves the patient. 

Such cases sometimes show a vegetating ulcer covered with granu- 
lations on both sides of the labia majora, extending down to the 
perineum and the anus. The vulva, edematous and infiltrated, may 
reach an enormous elephantiasic size. The edges of the ulcer may be 
neatly cut, made up by the agglomeration of hard, infiltrated nodules, 
showing a round disposition. The labia minora may be nearly all 
destroyed by the ulcerative process extending inside to the ostium 
vaginae. 

The process is slow and the antisyphilitic treatment is of little 
benefit, yet in some cases when the disease has not gone too far. curet- 

9 Huguier. " Memoire sur l'Esthiomene, on dartre rougeante de la region 
vulvo anale." Paris, 1849. 

10 Hyde, J. N. Jour. Cut. and Genit. Urin. Diseases, April and May, 1889, 

11 Taylor, R. W. New York Medical Journal, 1890. 



60 THE MEDICAL ASPECTS 

ting of the ulcer with local applications of a solution of I : iooo of 
bichloride of mercury has brought about recovery. We recognize that 
tubercular processes of the vulva are of rare occurrence, and are but 
rarely found in children, as a result of secondary uterine tuberculosis. 
In general these extended ulcerative processes must be attributed to 
syphilis, but in some cases it is easy to see that syphilis is associated 
with tuberculosis and one has an influence on the other, and both to- 
gether cause horrible destruction. 

Of course the gummatous syphilitic process has to be differentiated 
from tuberculosis, as both are entirely different processes. Indeed, we 
have a great many interesting differential points taken from the time 
of appearance of the disease ; gumma, as an expression of late syphilis, 
appears later in life, while lupus is seen much earlier. The course of 
the syphilitic process, although very slow, is yet more rapid than lupus. 
It is very rare at the time of the appearance of the gumma not to find 
some other signs of syphilis present, and also the therapeutic argument 
that a syphilitic gumma improves under specific treatment, while lupus 
does not show any sign of improvement. 

A gummatous ulcer should not be mistaken for miliary tuberculosis 
of the skin, which is rather a rare affection, and shows an acute process 
leading to disintegration. Its flat appearance, the yellow reddish color 
of its bottom, the nibbled condition of the borders, the presence of small 
whitish miliary nodules surrounding the ulcer on a red inflamed skin, 
will be important signs for differentiating miliary tuberculosis of the 
skin from syphilis. Then there has to be added that miliary tuber- 
culosis of the skin always comes when the process of tuberculosis is 
very much advanced, and the patient is greatly run down; it is then 
very easy to make the diagnosis. 

The onlv obscure cases remain when an individual affected with 
tuberculosis has acquired syphilis and both diatheses are found together. 

Svphilis at a late period is the cause of elephantiasis of the penis 
and scrotum in the man, and of the labia in the woman. In the man 
the skin of the penis takes on great proportions, so as to be increased 
many times its natural size. 

SYPHILIS OF THE ORO-PHARYNGEAL CAVITY 

It is frequently found that the initial lesion has its seat on the 
lips, tongue, mucous membrane of the cheeks, palate, tonsils. In such 
cases it is easily communicated in an innocent way by kissing, or by 
objects of ordinary use. The seat of the chancre, however, has no in- 
fluence on the secondary lesions which affect the oral cavity. After 
the period of the second incubation, or when the initial chancre has 



Plate VIII 




Phagedenic Syphilitic Ulcer 
With elephantiasis of the anus and vulva 



CONSTITUTIONAL SYPHILIS 6l 

lasted from four to six weeks, together with the symptoms of a general 
reaction, the mucous membrane of the mouth shows hyperemic patches 
in the form of erythema. Some are small patches the size of a penny, 
sharply defined, raised above the level of the normal epithelium, and 
are found on the lips, cheeks or tongue. A form of reddish, diffused 
erythema is found spread on the soft palate, faucial tonsils, and on the 
uvula, and has been called erythematous syphilitic angina. It makes 
its appearance at the time of the first breaking out of the roseola on 
the skin, and sometimes precedes the eruption a few days, and it is 
then the first constitutional manifestation of syphilis. 

It causes a very slight subjective sensation, so that many patients 
scarcely notice that they have any throat trouble. It is noticed at 
first as a sensation of dryness, and then an increased formation of 
mucus takes place. Syphilitic erythema of the throat sometimes lasts 
from six weeks to several months, and spreads over the velum palati. 
the palatine arches, the tonsils and the pharynx. In many cases it 
retrogrades, leaving, however, a red erythema on the arches of the 
palate. In other cases, it happens that the epithelium is lost in spots 
and superficial erosions remain, covered with some whitish detritus, 
showing a narrow area of infiltration, which is liable to make the move- 
ment of deglutition painful and laborious. Gradually the infiltration 
declines, the erosions become covered with epithelium and heal up, the 
bluish red color of the mucous membrane takes a rusty brown color, 
with enlarged blood vessels, which remain for a long time as a witness 
of syphilis. 

This condition of the throat appears also at the time of the cuta- 
neous erythematous syphilide, yet it runs its course independently of it. 
It frequently recurs during the first year, and sometimes also during 
the second year after the infection. 

The mucous membranes are affected by papules in the same way 
as the skin. The papules in the mucous membranes are flat, reddish 
elevations the size of a lentil or larger, sharply denned, slightly in- 
filtrated and very slightly raised above the surface. The redness soon 
gives place to an opaque dullness, the epithelium assuming a bluish 
white or a pearl-colored appearance, more or less loosely adherent. 
They are called mucous patches. 

Mucous patches are very frequently found on the free edge of the 
lips, on the mucous membrane of the cheeks, on the tongue, especially 
on the border, tip and sublingual surface, on the tonsils, soft palate, 
faucial tonsils, but rarely on the posterior wall of the pharynx. 

The mucous patches situated in parts where the mucous membrane 
is in continuation with the skin, have the appearance of the mucous 
patch on the mucous membrane and that on an excoriated papule on 



62 THE MEDICAL ASPECTS 

the skin. After the mucous patch has lasted for some time, the thick 
epithelium is thrown off, and the place is left with a thin covering, while 
the whitish raised-up borders go down and disappear. 

When the mucous patches are neglected, they increase in size and 
in number, closely covering the tonsils, the arch of the palate or the 
border of the tongue, and on account of fissures or abrasions, become 
very painful. They also undergo a superficial necrotic process, forming 
painful ulcers. 

The irritation caused by the use of tobacco, either in smoking or 
chewing, is the cause of the ulceration of the mucous patches in the 
mouth. These ulcerated patches together with fissures which are pro- 
duced by the infiltration of the mucous membrane, cause such a swell- 
ing of the tongue and tonsils as to render the movements and functions 
of these parts exceedingly painful. 

In consequence of the suppuration of the ulcerated mucous patches 
of the pharyngeal cavity the lymphatic glands of the neck and of the 
submaxillary region become greatly swollen and painful and in some 
cases end in an abscess. 

In some cases of mild syphilis an eruption of a few papules in the 
oral and pharyngeal cavity are the only visible signs of the constitu- 
tional disease. In these cases the eruption of the few papules is pre- 
ceded by a slight feverish reaction, and they occur as an erythematous 
surface of the pharyngeal ring. 

When the mucous patches are kept clean and treated, they dis- 
appear in from two to four weeks without leaving any trace ; but when 
they have been ulcerated through the irritation caused by the use of 
tobacco, or by stumps of teeth, they remain for months and frequently 
recur. Mucous patches of the mouth and throat are stubborn syphilitic 
symptoms ; they recur very frequently during the first and second 
years after the infection, even when all other symptoms have subsided. 
The mucous patches in late recurrences are confined to a few whitish 
papules, which rapidly disappear, but are soon replaced by others in 
another locality. The patches at a late period are not very much in- 
filtrated, and are depressed in the center, showing a kind of annular 
shape, principally affecting the lips and the tongue. From the pres- 
ence of the patches in the oral cavity, the epithelium, especially that 
of the mucous membrane of the cheeks, undergoes a peculiar change in 
its appearance, forming a kind of diffused whitish patch, of different 
intensity according to the severity of the lesions. In some cases, from 
the angle of the mouth running back towards the last molar tooth, the 
epithelium is thick, hard and sclerosed, of a white mother of pearl 
color, with small elevations making the mucous membrane uneven. 
In some cases the epithelium is only superficially affected, showing a 



CONSTITUTIONAL SYPHILIS 63 

whitish yellow discoloration affecting the folds of the mucous mem- 
brane ; at other times there results a kind of a whitish stripe running 
unevenly from the angle of the mouth towards the last molar tooth. 
This condition of the mucous membrane of the oral cavity is a nearly 
constant or a permanent one. We have pointed out these whitish 
patches of the cheeks as one of the constant signs testifying to the 
evidence of an old syphilis. 

The recurrent patches on the lips and tongue make the patient a 
constant danger to healthy people on account of syphilitic contagium. 
Of course kissing is the most dangerous act for the transmission of the 
disease, especially to children; but it is also possible that syphilis be 
inoculated through towels or by different utensils which have been 
used previously by the infected person. For this reason it is necessary 
to use great caution in employing people in the household, especially 
in the quality of cooks when there is a suspicion of syphilis. 

The Oral Cavity — The submucous tissue of the mouth is often the 
seat of gummatous foci. They appear as nodes the size of a pea to 
that of a bean or greater, bulging over with the reddened mucous 
membrane. 

At first they are firm and hard to the touch, but later they become 
soft, the mucous membrane is broken and an ulcer is formed. The 
ulcer, according to its seat and quantity of infiltration, assumes dif- 
ferent appearances ; but it is sharply defined and on a red bluish base. 
It remains at first stationary, covered with yellowish grayish detritus, 
then clears up and finally heals, always leaving a cicatrix. In some 
unfortunate cases, gummata of the mouth take an acute destructive 
character, as above stated, producing great impairment in its functions. 
The tongue is often affected with gummata, as firm tumors felt in its 
substance. They break down and leave ulcers, which produce great 
pain in the movements of the organ. We more frequently meet with 
gummata of the hard palate, and these lead to the exposure of the 
bone. The bone falls into necrosis and is perforated, leaving a com- 
munication between the oral and the nasal cavity. The soft palate is 
also easily destroyed by gummata on account of its thin and delicate 
structure. In our service in the City Hospital we have not rarely seen 
the destruction of the whole soft and of a large area of the hard palate, 
making deglutition very difficult and painful, and speech very nasal in 
tone. 

The tonsils and the pharynx are often affected with circumscribed 
gummata, which, breaking down, cause ulceration. The patient suffers 
great distress in consequence of dryness and rawness of the throat, 
which is relieved for only a short time by gargling. 

The diagnosis of the syphilitic affections of the mouth is not dif- 



64 THE MEDICAL ASPECTS 

ficult. The only disease which deserves mentioning is the stomatitis 
mercurialis. The absorption of mercury for the treatment of syphilis, 
no matter how and in what form administered, in many patients will 
lead to the inflammation of the gums and of the mucous membrane of 
the mouth, with an increased flow of saliva (salivation). This causes 
swelling of the gums, with a grayish yellow edge where they are in 
contact with the teeth, swelling of the cheeks and, in advanced cases, 
also of the tongue, on which the teeth leave their imprint. The patient 
complains at first of a metallic taste, and soon gives off an offensive 
odor from his mouth, which increases with the production of the ulcers 
on the gums and cheeks. These ulcers are shallow, of a grayish white 
color from necrotic detritus, and surrounded by inflammatory redness. 
In these cases, if the use of mercurials is not stopped, it may lead to 
the necrosis of the tissues, and also of the jaw. 

In some cases, in the mucosa of the cheeks and of the lips, more 
rarely of the hard palate, are formed milk white spots, opaque, irreg- 
ular in shape, just as if the mucous membrane had been touched with 
a stick of nitrate of silver ; the epithelium is hard, thick, and wrinkled, 
and causes a sensation like tanned skin. Sometimes they also appear 
on the edges and on the back of the tongue. In these white places 
the tongue is smooth, deprived of its papillae, while the rest of the 
tongue is red, thickened and studded with red elongated papillae. It 
is the condition of the tongue which was described as keratosis Ungues 
by Kaposi, plaques lisses by Fournier, leucoplakia by Schwimmer. 
These patches are more frequently found in persons addicted to ex- 
cessive smoking, and, for this reason, they have also been called 
plaques des fumeurs by Buzenet. But according to many authors and 
to our own observation, these callosities of the mucous membrane of 
the mouth, if they are not the direct result of syphilis, they are surely 
greatly favored by it in their development. These patches are not 
influenced by antisyphilitic treatment and remain for years entirely 
unaltered. 

We will only mention the possibility in the oral cavity of lupus, 
which, like syphilis, leads to disintegration and loss of substance. It 
closely resembles syphilis and it requires some study to differentiate 
the two diseases. The ulcers from lupus are usually of a pale red 
color, granulating, and surrounded with nodular growths, which are 
lupus foci. In the ordinary cases lupus of the oral cavity is only a 
reproduction of lupus of the face, and the presence of lupus nodules on 
the face or of scars will facilitate the diagnosis. But we cannot for- 
get that in exceptional cases lupus begins on the mucous membranes. 

Miliary tuberculosis also affects the tongue, the palate and the 
pharynx in the form of tuberculous ulcers, which can be mistaken for 



, 



Plate IX 







An 
<| 

O 



1 B 

M 


f 



PM 
PL. 

H 

< 



u 



CONSTITUTIONAL SYPHILIS 65 

syphilitic ulcerations. Tuberculous ulcers sometimes are primary, but 
are often secondary to tuberculosis of the lungs or of other organs. 
The tubercular ulcers have a cheesy, lardaceous bottom, with under- 
mined sloughing edges, of a bluish-red color, studded with tubercular 
nodules. Tubercle bacilli are easily demonstrated in the discharge or 
in the substance of the nodules. Tubercular ulcers usually have their 
origin on the tonsils and on the vault of the pharynx, extending to the 
velum palati and to the back portion of the pharyngeal cavity, but they 
remain sharply limited at the beginning of the esophagus. They are 
accompanied by such extreme pain that the patient cannot take nourish- 
ment. Fever is often present, and symptoms of general tuberculosis 
will be easily found, so that the doubt between syphilis and tuberculosis 
cannot remain long, unless as we have already mentioned, both diatheses, 
are mixed together. 

The lips, the mucous membrane of the cheeks and tongue, are af- 
fected with carcinoma, and there may sometimes be doubt in the- 
diagnosis with reference to syphilis. In the beginning of the develop- 
ment of carcinoma it may be mistaken for an initial lesion of syphilis, 
but the condition of the enlarged glands will soon show the syphilitic 
lesion, while in carcinoma the glands are not affected until later. 

Gummata usually affect any one of these parts in several places, 
at the same time, while carcinoma usually begins as only one lesion. 
In cases, however, where the carcinoma or gummata have been for 
some time, and when the surface is covered with papillary growths, it 
is rather difficult to make a differential diagnosis between the two. 
Moreover, we have already mentioned that not rarely carcinoma has 
its origin in ulcerated syphilitic gummata of the mucosa of the mouth. 
In some cases we resort to the antisyphilitic treatment to see its in- 
fluence, and the kind of affection we have to deal with before perform- 
ing a radical operation. 

Many other affections which have no relation to syphilis may 
create some doubt concerning it. Some papillomata are often found 
on the gums or cheeks and may be ascribed to syphilis. In the same 
way a peculiar and rare affection of the tongue, glossitis cicatrisans, 
may also be mistaken for a syphilitic manifestation. 

SYPHILIS OF THE ALIMENTARY TRACT 

Although syphilis affects every organ of the body, yet we can 
state that syphilitic lesions of the esophagus and stomach in the secon- 
dary period are only exceptions. Cases of dysphagia are quite often 
the result of syphilitic ulcers of the pharynx or larynx ; and there have 
also been observed cases of dysphagia from paralysis of the esophagus. 



66 THE MEDICAL ASPECTS 

in the course of syphilis, which disappeared under specific treatment. 
Cases of cicatricial obstructions of the esophagus have been referred 
to, which had been the result of ulcerated gummata. In these cases 
the symptoms of obstruction have appeared only late after recovery 
from syphilitic attacks. 

It is quite a rare thing to find syphilitic affections of the stomach, 
but not exceptional. In our practice we have met, in individuals who 
had suffered with severe symptoms of syphilis, cases of anorexia, pain- 
ful sensation in the stomach, vomiting after the ingestion of food, all 
of which have disappeared under the administration of mercurials and 
of iodide of potassium. 

There have oftener been observed and demonstrated syphilitic 
affections of the intestines produced by syphilis, and we very frequently 
have occasion to see cases of syphilitic enteritis in children affected 
with congenital syphilis. In the early period of syphilis we find cases 
of stubborn diarrhea, which are only relieved by the use of small doses 
of calomel. Cases of diarrhea, however, are found as the result of 
hydrargyrosis, and in this case it is necessary to stop immediately the 
use of mercurial medication. 

The rectum is a region which is often affected with syphilis, be- 
ginning with the initial lesion and passing through all the stages to the 
gumma. Mucous patches are found around the anus in the form of 
rhagades, which are very painful and bleed at the time of defecation. 
Mucous patches affect the inferior portion of the rectum, and on ac- 
count of the continuous irritation to which they are exposed, grow to a 
large size and may cause troubles resembling those produced by can- 
cerous stricture of the rectum. 

Gummatous productions of the rectum are also frequently found. 
They easily ulcerate and produce destruction of the mucous membrane 
of the rectum, leaving the muscular layer exposed, which is also 
riddled by the ulcers. In these cases the patient has involuntary stools, 
which are watery and bloody, accompanied by tenesmus. When the 
ulcers heal, stricture of the rectum is often the consequence. 

SYPHILIS OF THE RESPIRATORY TRACT 

If we consider the respiratory tract, we find, to begin with, the 
nose, which is sometimes the seat of an initial lesion. During the 
secondary eruptions it is often affected with irritative forms of syphilis, 
either of the erythematous or the papular form. This condition pro- 
duces a syphilitic nasal catarrh, which is noted for its obstinacy, lasting 
for months, with an abundant purulent secretion. 

The parts of the nose accessible to examination show a diffused 



CONSTITUTIONAL SYPHILIS 



6 7 



redness of the mucous membrane, and, in the vicinity of the nostrils, 
mucous patches are found, usually covered with a yellow grayish secre- 
tion. It is due to the syphilitic rhinitis that some patients complain of 
headache in the frontal region, which disappears when the rhinitis 
subsides. 

Superficial gummata affect the skin of the nose, which after ulcer- 
ating may produce destruction of the cartilage, with permanent de- 
formity of the alae of the nose. Gumma of the pericondrium of the 
cartilage, and of the periosteum of the nasal bones, causing destruction 
of the hard structure of the nose, has been of not infrequent occurrence 
in our observation. A gumma of the pericondrium may cause necrosis 
of the cartilages and bones, destroying all supporting parts of the nose. 
The lady who had been infected by marriage belonged to a class of 
cranks who believe they can have all diseases cured by prayer, and only 
when the nose was in the condition shown by the illustration did she 
decide to ask for medical attendance. 

The septum nasi is often perforated and even destroyed by a gum- 
matous process, causing both nostrils to coalesce in a large opening. 
Sometimes the nose, remaining without the support of the septum, 
sinks in the form of a small triangle. Sometimes a gummatous process 
affecting the mucous membrane and ulcerating deeply causes necrosis 
and exfoliation of the cartilages and bones. 

The first appearance of the gumma of the nose is marked by a 
dull pain, which is followed by a swelling which causes obstruction to 
the passage of the air. The nose takes on a brownish bluish color, and 
is greatly swollen at the bridge, and later becomes edematous. When 
the gumma breaks down from the inside a mucopurulent secretion 
comes out ; in some cases the secretion dries into a thick crust, which 
adheres to the wall of the nose. A new purulent secretion detaches 
these crusts, so that at times they are thrown off. The purulent secre- 
tion remaining in the coanae of the nose becomes decomposed and causes 
a foul smell. The bones are discovered to be necrotised and exfoliat- 
ing, and sometimes the patient on blowing his nose blows out small 
pieces of bone. If the affection is in the turbinates, the result is not 
of so great importance, but when the necrosis extends to a greater 
portion of the bony structure, the nose is deprived of its support, falls 
down, and deformity is the consequence. When, for instance, the per- 
pendicular plate of the ethmoid is destroyed, the nasal bones sink down, 
the bridge of the nose is bent down like a saddle and the tip is tilted 
upwards, causing a hideous deformity, which reveals the nature of the 
process which has taken place. 

In some cases the gummatous process spreads to the horizontal 
plates of the palatal bones, and produces a perforation of the hard 



68 THE MEDICAL ASPECTS 

palate. In some cases the perforation which results may be so large 
as to enable one to inspect the cavity of the nose from the mouth. It 
causes distress in mastication and in deglutition, when the food enters 
the nasal cavity from the mouth. The adjacent sinuses are not spared 
and the gummatous process finds its way into the antrum of Highmore, 
into the sphenoidal and into the frontal sinuses. In this way on ac- 
count of the infection of the frontal sinus, we can explain the violent 
pains in the forehead which accompany syphilitic ozena. 

In reference to the olfactory functions, it is interesting to mention 
that in these cases of rhinitis the smell of which is noticed by others 
does not affect the patient, either on account of being accustomed to the 
continuous bad odor, or on account of the blunting of the sense of 
smell. In the first case the patient, although not noticing the bad odor 
of his nose, is still capable of noticing other odors ; but in the second 
there is complete anosmia. 

On account of the diseased condition of the upper portion of the 
mucous membrane of the nose, where the ramifications of the olfactory 
nerve are spread, the function of smell may be destroyed. In other 
words, anosmia may be only temporary, and it is the result of the 
swelling of the mucous membrane covering the middle turbinated bones, 
occluding the olfactory fissure between the middle turbinated body and 
the septum. When the swelling subsides and the permeability of the 
olfactory fissure is restored, the sense of smell will gradually return. 

The larynx is quite often affected by syphilis in the early and late 
stages. During the early period of syphilis, it is an erythematous af- 
fection of the mucous membrane in the form of a catarrh — catarrhal 
laryngitis. It is limited to a redness only, and a superficial swelling 
of the mucous membrane, which in some cases, on account of increased 
infiltration, may cause superficial abrasions, and, in some grave cases, 
infiltration extended to the muscles with resulting paresis. 

The erythema, in most cases, is diffused to the whole mucous mem- 
brane ; but in some it may be limited to single parts, such as the 
epiglottis, the aryepiglottic folds, false vocal cords, etc. As a conse- 
quence, the patient shows different degrees of hoarseness according to 
the process, which may lead to aphonia. The quantity of secretion 
causes the patient to cough and hack in order to get rid of the secre- 
tion. 

In most cases the laryngeal catarrh is one of the first symptoms 
of constitutional syphilis, and accompanies the erythema of the palate 
and pharynx. Sometimes it comes after the condition of the pharynx 
has improved, and is one of the relapsing affections, especially in per- 
sons who by their occupations are often exposed to the cold air. 

Mucous patches affect the larynx only in rare cases, to the extent 



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CONSTITUTIONAL SYPHILIS 69 

of three in one hundred syphilitic persons. The mucous patches in the 
form of small lentils appear on the free edge of the vocal cords, in a 
rather elongated shape, covered with grayish epithelium, or excoriated, 
or even ulcerated. They cause complete aphonia, as we had occasion 
to observe in two of our cases, lasting for seven weeks. Another fre- 
quent site of the mucous patches is the free edge of the epiglottis, ex- 
tending towards 'its posterior surface; sometimes the ary epiglottic 
folds and the mucous membrane of the arytenoid cartilage are invaded. 
In a case referred to by Armand Despres an ulcerated proliferated 
patch on the right vocal cord was the case of so severe a dyspnea 
that it was necessary to resort to tracheotomy. 

Mucous patches of the larynx usually terminate through involu- 
tion, and although they break down, they are easily healed. 

Like other organs, the larynx, too, at a late period of syphilis, is 
affected by gummata, which attack the vocal cords either in the form 
of small nodules or in the form of diffused gummatous infiltration. A 
man, thirty-five years of age, who had shown periosteal gummata of the 
tibiae, began to develop complete aphonia. On the right side of the 
rima glottis three little, round reddish brown nodules covered nearly 
the entire vocal cord, preventing the formation of the voice. 

The gummata frequently undergo suppuration, leaving ulcers, with 
neatly cut edges from the infiltration. The resulting ulcers in for- 
tunate cases usually heal up, but in some other cases the cartilages 
may remain uncovered, causing necrosis with extensive destruction of 
the organ and permanent impairment of the phonation. In some cases, 
on account of the defect of the epiglottis or of the imperfect action of 
the muscles of the larynx, fluids or particles of food enter the rim of 
the glottis during deglutition, with severe annoyance to the patient 
until he has gotten into the habit of preventing it. 

After cicatrization, the loss of substance may produce all kinds 
of disorders, according to the location and extension of the destruction. 
Small ulcers may heal up easily without leaving scars, but the vocal 
cords are so sensitive that any small superficial scar may impair nor- 
mal intonation. 

When the destruction has been of considerable extent, the result- 
ing cicatrix may cause adhesions of the vocal cords, leaving a small 
opening, or adhesions of the other parts of the larynx. 

Only rarely have syphilitic lesions been traced below the larynx 
into the trachea and bronchi, but it is more than probable that some 
cases of bronchial catarrh in the first period of constitutional syphilis 
are due to the irritative syphilitic process, similar to that which affects 
the soft palate, pharynx and larynx. 

Papules on the trachea have been described in a few cases by 



70 THE MEDICAL ASPECTS 

Seidel and Mackenzie. But the lesions more frequently observed are 
gummata, not in the isolated nodules, but as a uniform infiltration. It 
gradually ulcerates, the cartilages remain exposed, necrosis takes place, 
and when detached, are expectorated in the form of small necrotic 
scales. In most cases the trachea is affected together with the larynx, 
and it seems that it is only the extension of the process ; but in a 
few cases gummatous infiltration of the trachea can be demonstrated 
independent of the larynx. 

Tracheal syphilis may have an easy termination, the infiltration 
may be absorbed, the ulcers cicatrized; but deformities of the trachea 
are often the consequence. If an entire ring has been destroyed, the 
trachea will appear shortened, but if only half of the ring has been 
destroyed, the trachea will be bent, and both deformities will be ac- 
companied with some narrowing of the lumen. 

Stenosis of the trachea may follow gummatous infiltration and 
ulcers independently of necrosis of its cartilages. The gummatous 
infiltration sometimes causes an evenly spread stenosis of the trachea 
from above downwards. Ulcers may cause uneven cicatricial tissue, 
running from one side to another, producing a kind of net-work in 
the trachea. In these cases when mucus remains there, some dyspnea 
is produced, which is only temporary. When ulcerations are present 
on the mucous membrane of the trachea, the muco-purulent secretion 
is always increased, and is accompanied by rales, cough, and sometimes 
pain behind the sternum. 

In consequence of tracheal syphilis the patients are exposed to a 
great danger resulting from possible perforations into the esophagus 
or into the large blood vessels, causing a fatal hemorrhage. 

Stenosis of the trachea is the result of gummatous infiltration 
and resulting ulcerations after their healing. They come slowly and 
are revealed by dyspnea, especially during the inspiration, and the 
voice loses some of its resonance. 

The lungs when affected by syphilis show gummatous nodules, 
which are rarely single, but usually multiple and on one side. The 
middle and lower lobes are more frequently affected, but the apex 
has also been found infiltrated with gummata. These are round, from 
the size of a pea to that of a walnut, and of a grayish red color. The 
surrounding pulmonary tissue is infiltrated on account of a chronic 
limited pleuropneumonia or bronchopneumonia, which is the result 
of the presence of the gumma. The inflammatory process produces 
either on the surface of the organ underneath the pleura, or around 
the small bronchi, firm callous foci of cicatricial nature, hard to the 
touch, consisting of sclerotic connective tissue. 

The hyperplasia of the connective tissues is plainly visible, start- 



CONSTITUTIONAL SYPHILIS yi 

ing either from the walls of the larger bronchi, or from the adventitia 
of the pulmonary vessels. In some cases it results in stenosis of the 
bronchial tubes, and in others in bronchiectatic cavities from cicatricial 
contraction. 

Pulmonary syphilis also affects the lungs in the form of a diffuse 
infiltration in one or in both. The pulmonary tissue, becomes firm, 
homogeneous, devoid of air, and of a yellowish red color. The process 
starts from the interstitial connective tissues and from the walls of 
the arteries and of the bronchi. This form is found mostly as a con- 
sequence of congenital syphilis. 

Another form attacks adults as catarrhal pneumonia in which an 
entire pulmonary lobe is found firm, of a pale reddish gray color, 
devoid of air, and at the cut shows a peculiar gelatinous appearance. 

In the symptoms we have no characteristics by which to decide 
whether a catarrhal form of the lungs is due to syphilis or not. The 
syphilitic symptoms present, together with a catarrhal condition of 
the lungs, of a stubborn and protracted course, will suggest the 
syphilitic origin of the pulmonary affection. 

We have had occasion to observe a few cases of pulmonary af- 
fections produced by syphilis. One occurred in an old gentleman who 
was suffering with a diffuse papular eruption eight months after the 
infection. He was taken ill with an acute pain in the right chest, 
dyspnea, cough and fever. This condition lasted for several weeks 
and, when the dyspneic condition was at its height, he expectorated 
a large quantity of pus, after which the symptoms gradually subsided 
and recovery was the result. 

Another case came under our observation four years after in- 
fection, and after undergoing very severe and persistent syphilitic 
symptoms. The pulmonary affection began with difficult respiration 
and a dry and obstinate cough, which was followed by enormous 
hemorrhages of the lungs. The condition of the lungs seemed more 
suggestive of a case of tuberculosis, but in the expectoration we 
could never find tubercle bacilli, and from the fact that the patient has 
recovered we have been inclined to maintain that the case was one 
of pulmonary gummata. 

The cases observed have been found in individuals who had suf- 
fered from syphilis for several years. The symptoms referred to are 
first difficult respiration, which reaches the point of a true dyspnea, 
when catarrh supervenes, followed by a cough, scanty expectoration 
and slight pain. This condition, which is worse in the evening and 
better in the morning, may last for some time. Gradually with the 
progress of the affection the respiratory movements of the thorax 
become impaired. The infiltration of the lungs is revealed on per- 



72 THE MEDICAL ASPECTS 

cussion by a dull sound, weakened respiration, increased bronchial 
inspiration, and shortened expiration. 

The gummata undergo the destructive process and cavities are 
formed. Dyspnea, pain and cough increase, expectoration becomes 
abundant and purulent, and at times profuse bleeding is observed. 
The patient becomes weak, his appetite is lost, fever begins and a 
cachectic condition will finish the picture of the pulmonary phthisis. 

Children with congenital syphilis quickly succumb to pulmonary 
trouble. In adults, however, when they preserve their strength, there 
is the hope that with an antisyphilitic treatment they can be brought 
to recovery. 

The diagnosis between tuberculosis and syphilis of the lungs is 
sometimes difficult. It is necessary to remember that the syphilitic 
gumma affects the lungs in the middle, and the physical signs are 
found towards the angle of the scapula, and more frequently on the 
right than on the left side. The accompanying syphilitic symptoms, 
such as periostitis, and scars of subcutaneous gummata will be very 
valuable in enabling us to establish the differential diagnosis. Both 
diatheses may exist together, and in this case it is difficult to establish 
the differential diagnosis between a tuberculous and a syphilitic pul- 
monary affection. 

SYPHILIS OF THE HEART AND BLOOD VESSELS 

The same process which takes place in the skin may affect any 
other tissue and any other organ of the body, the only difference is the 
anatomical structure in which the syphilitic lesion takes place. It is 
not the cell of the bone, or the nervous cell, which is directly affected 
by syphilis; but from the blood vessels or from the lymphatics, as a 
consequence of an angioitis an accumulation of lymph cells is formed, 
which cuts off the supply of the nutrition to the cells of the tissues, and 
consequently they are affected with necrobiosis and die. In every 
gumma we find blood vessels affected in their tunics by an infiltrating 
process, and also lymph-vessels enlarged, obstructed and inflamed, 
showing that the formative process of the granulation has begun from 
them. The process, therefore, is always the same; the difference is in 
the tissues affected, and the way in which they react in the developing 
affection. 

Cases of affection of the heart in syphilis have been reported by 
Ricord, Lebert, Virchow, Wagner and others. Gummata are fre- 
quently found in all the muscular parts of the heart, in the walls of 
the ventricles, auricles, and septum and in -the papillary muscles. 

A syphilitic myocarditis, independent of gummata, produces 



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CONSTITUTIONAL SYPHILIS 73 

fibrous cicatrices in its muscle with resulting partial aneurisms. Either 
gummatous or fibrous syphilitic myocarditis are associated with a 
sclerotic endocarditis, or with partial pericarditis. 

Endocarditis may attack the lining of the myocardium, or the 
valves near their insertion. In this case the valves are thickened or 
pushed aside by the developing gumma. Symptoms of insufficiency 
or of stenosis are the result of the deformity of the valve. 

The heart is affected by syphilis only at a late period, after it 
has existed for several years. 

In some cases the coronary arteries are affected by a sclerogum- 
mous arteritis, and in consequence the heart is affected with myo- 
malacia, and with callous formations of sclerotic connective tissues. 

In other cases the ganglia and the nerves of the heart, being 
involved in the sclerotic process, are the cause of different forms of 
angina pectoris. 

The course of the syphilis of the heart is usually latent. The 
disease lasts for a long time, until as a result of a violent effort or of 
an increase in the specific productions, a sudden change for the worse 
takes place. In most cases the patients die suddenly in consequence 
of paralysis of the heart, very rarely from the rupture of the muscle 
in the vicinity of the lesion. 

The symptoms, in general, are those of a chronic myocarditis, 
the patients complain of general weakness, palpitation of the heart, 
precordial pains; they often speak of a sensation of fear and oppres- 
sion in the chest and sometimes have dyspnea. Physical examination 
shows an increased cardiac dullness ; the heart sounds are in some 
cases normal, but are usually muffled and associated with a slight 
blowing murmur. The contraction of the heart is weak and unequal, 
with corresponding small and irregular pulse. The patient is pale 
and sometimes cyanotic, edema and dropsy develop and the urine con- 
tains albumen, but only rarely signs of insufficiency of the valves are 
present. The end of syphilis of the heart is usually fatal. Cases 
have been reported with a favorable termination after long and per- 
sistent antisyphilitic treatment. 

The syphilitic manifestations in the circulatory system have for a 
long time attracted the attention of pathologists as the part upon 
which the infectious influence of syphilis shows its deleterious action. 
The origin of the syphilitic lesions must be looked for in the vascular 
system, which forms a part in the intimate structure of nearly every 
organ and tissue. In the developed chancre the blood vessels already 
show the results of the attack of syphilis. Their alterations are no 
longer the result of a reaction, but the result of the infection in 
possession of the tissues. The nature of the lesions of the blood ves- 



74 THE MEDICAL ASPECTS 

sels in syphilis is exactly the same that we find in the stages of its 
evolution, representing in the secondary period a hyperplastic inflam- 
matory process like a specific irritation, and another in the tertiary 
period in the form of a gummatous infiltration. 

After the classical works of Hiibner and Baumgarten on syphilis 
of the cerebral arteries, the question of the alteration of the blood 
vessels in syphilis has been entirely cleared up, and they justify us 
in maintaining that aneurisms are produced directly by syphilis. 

The process affecting the arteries is a true arteritis of a specific 
nature, which causes an infectious degeneration of the blood vessels. 
The specific inflammatory process affects the artery in its totality, 
its tunics are greatly enlarged by the infiltration between their cellular 
elements. It is scarcely possible to distinguish the adventitia from 
the surrounding tissues, as the infiltrating cells are accumulated with- 
out a line of demarcation. The muscular tunics seem to be smaller 
and compressed. The intima is thickened more than the other tunics ; 
it is woven with hyperplastic young cellular elements concentrically 
disposed, the endothelial lining is greatly increased, so that the lumen 
of the artery is much diminished, and has also changed its normal 
shape. In some transverse cuts it looks quadrangular, in others 
rhomboidal, and in those remaining round it looks like a tunnel. In 
some cases the intima is so thickened as not only to diminish the 
lumen of the blood vessels, but also to obliterate it. 

Many blood vessels are found plugged up with thrombi, such as 
we have found in the lymph vessels. In the secondary stage the in- 
flammation of the artery causes an edema and an infiltration of 
leucocytes in its limited district, which was called by Renaut 12 cone 
arterielle. 

The arteries composed of elastic and contractile layers depend 
on their own vasa vasorum for their nutrition, through the plasma 
supplied by them to the media. The internal layers and the epithelial 
lining of the intima, however, must take their nourishment either by 
the media, or by imbibition from the circulating blood, as happens in 
the capillaries, which are destitute of vasa vasorum. It seems that 
syphilitic virus affects the arteries in the beginning, through the 
lymph spaces, because we find arteries in the initial sclerosis, when 
no virus is circulating in the blood, but it is undeniable that in later 
manifestations it comes through the infected blood, affecting the 
intima. The irritating action of the virus upon the intima of the 
artery produces an exudation which spreads through the walls of the 
artery into the surrounding tissues, and with its agglutinating proper- 

12 Renaut, J. " Sur la caracteristique anatomo-pathologique de la syphilis." 
Revue Pratique des maladies cutanees, etc. Janvier, 1903. 



CONSTITUTIONAL SYPHILIS 75 

ties causes coagulation of the serum and formation of the thrombus. 
Virchow 13 demonstrated that the endothelial cells of the intima are 
susceptible of proliferation, and in certain circumstances are also sus- 
ceptible of neoformation. For the larger blood vessels, however, it 
is more plausible that the syphilitic inflammatory process starts from 
their own vasa vasorum, as we could demonstrate in the basilar and 
in the subclavian arteries. 

The arterial lesions are in great part to be held accountable for 
the syphilitic manifestations in every tissue, and in every organ of 
the system. If we stop to consider for a moment the skin, we will 
easily see that the affection of the arteries must be considered the 
factor of the eruptions, from the roseola to the superficial ulceration. 
Since the publication of the works of Hiibner, the purpura of the 
new-born has been referred to the syphilitic alterations of the blood 
vessels. In papular eruptions and mucous patches the influence of the 
endoarteritis is clearly shown by the circumscribed limits of the 
chronic infiltration of the derma and its fibro-formation, which is re- 
vealed by the elongation and hypertrophy of its papillae. In the same 
way in the ulcerative process, and also in the gangrenous superficial 
gumma, the endoarteritis is responsible for the resulting ulcerations. 
In some cases the arteries are so greatly changed as to show how 
deep the deleterious influence of syphilis is on the vascular system. 
The intima especially is so thickened with cellular elements and with 
endothelial proliferation as to cause the lumen to become nearly 
obliterated. The gummatous process affects the blood vessels as well 
as any other tissue, and it is really in the blood vessels that we find 
the best representation of the fatty degeneration of the gumma. We 
have had the opportunity to see gummatous infiltration in basilar, 
auriculo-temporal and popliteal arteries. 

The production of the aneurism is due to the pathological condi- 
tion of the artery directly induced by syphilis. Lancereaux has already 
described an aneurism of the subclavian artery, which improved under 
the administration of the potassium iodide. G. W. M. McNalty 14 
observed in a soldier thirty-five years old an aneurism of the aorta 
which had made its appearance five years after the infection. He 
claimed that it was benefited by potassium iodide. The patient, how- 
ever, died and the post-mortem revealed numerous gummata in the 
heart and in the endocardium, with thickening of the aortic valves. 
The innominate artery and a portion of the arch of the aorta were 
converted into aneurisms. 

13 Virchow, R. " Ueber die acute Entziindungen der Arterien." Archiv. fur 
Path. Anat. und Phys. B.I. p. 274. 

14 McNalty. Quoted by Lang, 1. c, p. 148. 



76 THE MEDICAL ASPECTS 

Langebeck demonstrated in four cases of aneurism of the aortic 
arch, and in many other cases of aneurisms of the aorta, that the 
patient had suffered from syphilis. In a colored man who was treated 
in the Cincinnati Hospital for an enormous aneurism of the popliteal 
artery, we have found exostoses in both tibiae, an unmistakable sign 
of an old syphilis. The infection in that case had taken place nearly 
eleven years before the aneurism appeared. Cases of popliteal aneur- 
isms in syphilitic persons have been reported by James O'Grady, Hey- 
berg and others, as a result of syphilitic arteritis. According to our 
observations the principal cause of the rupture of the arteries causing 
aneurism is due to the sclerotic condition of the media. The media 
is, like the other tunics, infiltrated at first, its delicate muscular struc- 
ture compressed by the cellular infiltration becomes atrophic, inelastic, 
and therefore the pressure of the blood easily breaks its fibers, causing 
the aneurismatic sac. 

In many other cases, however, the syphilitic arteries are subject 
to an infiltration and hypertrophy of all the tunics so as to constrict 
the lumen of the artery and cut off or diminish the supply of the 
blood to the peripheral parts. 

We are indebted to the kindness of Dr. Greiwe, director of the 
Pathological Laboratory of the City Hospital, for the use of a specimen 
of the basilar artery affected with syphilitic arteritis at its point of 
division. It was enlarged in the form of a small olive, whitish outside, 
hard and solid to the touch. In the section, the artery was nearly 
closed, showing the lumen to be about the size of a pinhole with 
thick and infiltrated walls. The whole alteration consisted of a gum- 
matous tumor which had taken up the entire wall of the artery. 

To the microscopical examination the gumma of the basilar 
artery showed the infiltration mostly in the adventitia and intima, 
with a few fatty degenerated elements in a yellow mass, contained in 
a fibrous fundamental substance. The adventitia is thickened with 
an enormous infiltration, and also with proliferation of the corpuscles 
■of the connective tissues, which contain the round emigrated cells. 
Few scanty foci of fatty degeneration are present, scattered through 
the external tunic. The media is also infiltrated, but is so compressed 
and crowded that it is smaller and looks nearly atrophic. In the 
intima the elastic layer is greatly enlarged. Elastic fibers appear 
between the hyperplastic tissues and between them a thick infiltration 
of small cells with granular necrotic centers and with some giant 
cells in their midst. 

It is a true gummous arteritis, which has been regarded by 
Baumgarten as a form of syphilitic arteritis, histologically specific. 
In our specimens we could demonstrate that the gummous infiltration 



CONSTITUTIONAL SYPHILIS 77 

does not spare any layer, the adventitia and the intima being more 
frequently affected. In the retrogressive process of the gummatous 
infiltration, sclerosis takes place, which leads to cicatricial changes 
of the arterial walls. 

In the affected blood vessels it is easy to distinguish a gummous 
periangioitis, and a productive endoangioitis. The periarteritis is 
very likely the result of an infiltration, which arises from the lymph- 
spaces surrounding the vessel, and causes the enlargement and the 
thickening of the external wall, while the endoangioitis is marked 
by an infiltration of the elastic elements, and a production of large 
endothelial cells, with a tendency to restrict and diminish the lumen 
of the vessels. In consequence of some exudation from the intima, 
in many small vessels and also in vessels of medium caliber, the blood 
is coagulated, forming a thrombus which sometimes entirely closes 
the lumen of the vessel, at other times only partially. 

This condition of the blood vessels explains the hemorrhagic af- 
fections in hereditary syphilis and the effusion of the coloring matter 
of the blood in all syphilitic lesions, which, although in the secondary 
period, leave a pigmentation lasting for a long time. 

The vasa vasorum of the affected arteries show the same process 
of peri- and endoangioitis as we have found in the other tissues. In 
hereditary syphilis the blood vessels likewise show alterations. At the 
place of ramification of the placenta Hennig 15 found extravasated 
blood, calcification, edema, infiltration, in a word a true gummatous 
product, which he carefully described as masses surrounding the 
arteries of the placenta. Infiltrations have been found by Zilles 
around the umbilical veins, and also around the blood vessels of the 
chorion in luetic subjects. 

The same pathological alterations of the blood vessels are found 
present in new growths proceeding from syphilitic lesions. In a 
carcinomatous" production growing out of a syphilitic ulcer of the 
inferior maxillary bone, we have found the blood vessels infiltrated, 
and affected in the same way as in the ulcerated syphilitic patches on 
which it was implanted. The condition of the blood vessels in these 
growths positively shows the characteristic luetic angioitis, which 
recalls the fact that the cancerous stroma is implanted on syphilitic 
ground. 

The veins are not spared by the same inflammatory process. 
Small veins under the microscope appear in the same condition as 
the arteries, their walls show an infiltration of cells, the connective 
tissues are enlarged, the shape of the vein is elongated, and in many 
instances they are obstructed with thrombi. 

15 Hennig, K. " Beitrage znr Anatomie, Physiologie und Pathologie der 
Placenta." Leipzig, 1873. 



78 THE MEDICAL ASPECTS 

Mracek 16 found the same alterations in small and medium sized 
veins in cases of purpura in children affected by hereditary syphilis, 
so that he has attributed this affection to the alterations of the veins. 

Proksch 17 has given the most elaborate and complete history of 
the syphilitic affections of the veins, collecting a large number of cases 
from all authors who have written on this subject. 

The pathological alterations in the veins in consequence of syph- 
ilis consist in an irritative, hyperplastic, inflammatory process, and in 
a gummatous infiltration at a late period. The veins like the arteries 
in all their ramifications from the smallest to the largest are liable to 
undergo the same pathological alterations. 

Edwin Klebs 18 described an annular induration affecting the 
lumen of the vena porta produced by a gumma seated in the vicinity 
of the vena cava. Cases of syphilitic phlebitis of the vena saphena 
interna have been reported by Girdwood, Greenhow, Gayrand, Lang, 
Breda, Charvot, Mauriac, Cautra, Gosselin, Mendel and Thibierge, in 
many cases under the knee, and in a few cases above. Cases of 
phlebitis of the saphena externa have been reported by Gosselin, 
Hutchinson and Dittrich. Karl Huber found thrombosis of the same 
vein and Langebeck referred to a case of gumma and thrombosis of 
the femoralis, which reached the iliac externa. 

In the City Hospital we have had occasion to treat cases of 
syphilitic phlebitis of the saphena externa affecting the whole region 
of the leg under the knee, which gradually subsided under the use of 
mercurial ointment. In another case we found phlebitis and peri- 
phlebitis of the vena femoralis, which was surrounded by an enormous 
gummatous infiltration. 

The syphilitic lesions of the veins like those of the arteries are 
of different natures according to the stage of syphilis. In the early 
stage the inflammatory form is that of a syphilitic phlebitis, while in 
the late period it has a gummatous nature. The lesions sometimes 
involve the intima, sometimes the media ; but they more frequently 
start from the adventitia. The point from which the infiltration 
starts seems to be that of the vasa vasorum. The connective tissues 
surrounding the veins in some instances are involved in the inflam- 
matory process and in these cases we find periphlebitis. 

Syphilitic affections of the cerebral veins have been described by 
Birch-Hirschfeld, to be of the same character as those described by 
Hiibner in the syphilitic arteries of the brain. 

16 Mracek, F. " Syphilis hemorrhagica neonatorum." Arch. f> Derm, und 
Syphilis. Wien, 1887. XIX, p. 117. 

17 Proksch, I. K. " Ueber venen-syphilis." Bonn, 1898. 

18 Klebs, Edwin. " Handbuch der pathologischen Anatomie," 1. 1st Abh., 
p. 447- 



CONSTITUTIONAL SYPHILIS 79 

Syphilitic alterations of the ramifications of the vena porta in 
the parenchyma of the liver have been described by Rokitansky, Dit- 
trich and Virchow; and Arnold Beer, in 1867, showed that the hyper- 
plastic interstitial inflammation of the ramifications of the vena porta 
are the cause of the syphilitic alterations of the liver. 

It is scarcely necessary to say that the symptoms connected with 
the syphilitic affections of the blood vessels are different according 
to the location and extent of the disease, the size of the affected ves- 
sels, and to the importance of the organ whose circulatory region is 
the place of the affection. The blood vessels lose their elasticity and 
become greatly thickened. Their lumen in some cases is enlarged, 
but is usually narrowed and in some cases obliterated, being unable 
to perform their functions of the nutrition of the tissues in the normal 
way. The thickening and the infiltration of the vessel tunics, and 
also the disposition to the formation of the thromboses, makes the 
blood vessels liable to break, producing capillary hemorrhages with 
arrest or, at least, an impairment of the nutrition of the tissues. The 
blood vessels, thickened and narrowed with gummatous production, 
and also obstructed by thrombi, prevent the circulation of the blood 
in the different organs and tissues, with resulting necrobiosis. The 
blood vessels affected in their stroma and in the arrangement of their 
tunics by the syphilitic virus may be recognized as the cause of 
serious dystrophies and malformations in the developing embryo. 

As a result of the diseased condition of the umbilical and placental 
vessels the fetus dies in utero. Foci of softening of the brain, ulcers 
of the skin, etc., are the result of prevented circulation of the blood 
through occlusion of the blood vessels. Hemorrhages are often caused 
by the rupturing of the blood vessels as the result of the syphilitic 
inflammatory process of their tunics. 

SYPHILIS OF THE LIVER, SPLEEN AND KIDNEYS 

Proceeding in the consideration of the organs as they are affected 
by syphilis we find that the spleen is frequently the seat of syphilitic 
manifestations. It is subject to those alterations revealed in the nutri- 
tion of the organs and tissues, called amyloid degeneration, which 
is found with marasmus and syphilitic cachexia. Virchow distin- 
guished two forms, a flaccid and an indurated one, the latter being 
more like the amyloid form. 

The gummata of the spleen are rare. Haslund had occasion to 
have post-mortems done in forty-four cases of adults who had died 
of acquired syphilis in the Commune Hospital in Copenhagen. He 
found that twenty-seven presented hyperplasia of the spleen, and 
three amyloid degeneration, but none showed gummata of this organ. 



80 THE MEDICAL ASPECTS 

Moskuleff 19 reported cases of pseudoleukemia produced directly 
by syphilis. He found in a woman affected with secondary lues the 
spleen enlarged, with a swollen condition of the lymph glands, and 
consequent leukocytosis. 

All symptoms disappeared after a strong mercurial treatment. 
Lang, in his clinic, has had the spleen examined in all syphilitic cases. 
In thirty cases of recent syphilis the spleen was found to be enlarged 
eight times its original size, it being necessary to note the fact that in 
four cases the patients had suffered previously with malaria. In one 
case he found a diminution in the size of the enlarged spleen, when 
the syphilitic symptoms began to diminish in intensity. In advanced 
syphilis, involvement of the spleen may be frequently seen. 

The liver, the spleen, and more rarely the pancreas are affected 
with syphilis, in the form either of a diffused chronic irritative inflam- 
mation or in the form of circumscribed gummatous nodules, with 
disastrous results to the functions of the organs and to the life of the 
patient. 

Syphilis as an infectious disease affects the kidneys in the same 
way that it affects the whole body, showing at times its bacterial 
action, at other times its bacteriotoxic influence. Nephritis occurs in 
different forms which can be grouped as acute nephritis, chronic 
diffused nephritis, chronic indurated nephritis, and as gummata of 
the kidney. From the records of la Charite, Spiess collected 220 
cases of post-mortems done in subjects who had died from syphilis. 
In 147 cases affections of the kidneys were present ; among them 42 
cases were found with amyloid degeneration, and 7 affected with 
gummata. Thirty-four cases were of congenital syphilis, of which 
10 showed kidney disease, and 3 amyloid degeneration, gummata 
not being found. 

E. Wagner, from the records of 63 cases of affected kidneys 
found in the post-mortems of syphilitic subjects, reported 3 cases 
of gummata, 35 of amyloid degeneration; and of the other cases, 
8 with acute and 4 with chronic nephritis, 7 of granular kidney, and 
6 with unilateral atrophy of that organ. 

H. v. Bamberger tried to establish the relation of Bright's disease 
to the other diseases, and in 1623 post-mortems he was able to 
determine in 49 cases syphilis as an etiological factor. Indeed, the 
characteristic product of syphilis is the gumma, and the other condi- 
tions of nephritis are common to any other nephritis caused by en- 
tirely different morbid agents. As a result it is difficult to say whether 
nephritis is accidentally accompanied by lues, or whether it is caused 

19 Moskuleff. Journ. fur haut und ven. Krank. Heft 4, 1902. Ref. in 
Dermatolog. Zeitschr. B. X., Heft 1, 1903. 



CONSTITUTIONAL SYPHILIS 8l 

by lues. In the same way the amyloid kidney, although found in 
syphilitic cachexia, occurs in consequence of tuberculosis, of tuber- 
cular affections of the bones, protracted suppurations from caries, 
etc. 

Of course nephritis from syphilis does not vary in its symptoms 
from nephritis arising from other infections ; but the presence of 
constitutional syphilis will show the syphilitic origin of the affection 
of the kidneys. It was believed that nephritis occurred only at a late 
period of syphilis, but it has been found with the earlier symptoms. 
E. Wagner referred to a case of acute Bright's disease, which appeared 
only six weeks after the infection and disappeared with the other 
symptoms after specific treatment. 

Indeed, there are luetic albuminurias which are only the first 
degree of a mild true nephritis, which can be considered either as the 
result of an attack of the bacteria, or as a parenchymatous degenera- 
tion of the epithelium from the syphilitic toxins, which produce 
morbid alterations in the secreting elements of the kidneys. 

Karvonen 20 has tabulated a large number of cases of nephritis 
from syphilis at all stages of the disease, showing that the kidney is 
affected quite often during its course, and is influenced by the anti- 
syphilitic treatment. One-third of the cases of acute nephritis have 
developed quite early, two months after the appearance of the initial 
lesion, some three months ; but after one year acute nephritis is only 
a rarity. This shows that nephritis cannot be the consequence of 
mercurial treatment which may act as an irritant substance affecting 
the epithelium of the segregating organs of the kidney, when in the 
first appearance of syphilis the patients had not yet been subjected to 
any treatment. But it is also possible that other causes favor the 
noxious influence of syphilis on the kidney, such as the abuse of 
intoxicants, the use of so-called antigonorrheal remedies, balsams, 
etc., which cause irritation of the kidneys. The pathological altera- 
tions which have been found in the acute syphilitic nephritis show 
that it may appear as parenchymatous, or as interstitial, but it oftener 
begins as interstitial nephritis. The symptoms of the acute luetic 
. neohritis are not different from those accompanying an ordinary 
/< nephritis and they especially resemble nephritis after scarlatina. It 
comes gradually, and as Fournier has remarked, it begins with a mild 
albuminuria, the patient maintaining his general condition unaltered. 
There is also another form which begins with stormy symptoms, 
enormous albuminuria, edema, etc., which is the result of a typical 
degenerative inflammatory nephritis. 

20 Karvonen, J. J. "Die nieren Syphilis." Dermatologische Zeitschrift. 
Berlin, 1900, p. 55. 



82 THE MEDICAL ASPECTS 

In the first of the interstitial type, the urine contains only a 
small quantity of albumen, with many leucocytes, a few hyaline and 
granular cylinders, and also, once in a while, a few red blood corpuscles. 
In cases where the interstitial alterations have gone very far on account 
of the compression of the canaliculi, and of the edema of the kidney, 
we find clear, scanty urine, with little albumin, few hyaline and granu- 
lar casts, many leucocytes and no epithelium. 

The glomerulonephritis, which is of a much more toxic nature, 
has symptoms altogether like those of any other parenchymatous 
nephritis. In these cases the patients are very pale and tired, often 
complain of a chill, which is not followed by fever, and pain in the 
renal region, which is increased by the slightest pressure. The urine 
is very scant, sometimes there is anuria. It has a high specific gravity, 
is turbid, sometimes contains blood, and always large quantities of 
albumin. It contains cylinders of all kinds, mostly epithelial, renal 
epithelium, red and white blood corpuscles and urates. The patient 
early shows some edema of the face, especially of the eyelids, and 
soon after some edema of the feet, which spreads to the whole body, 
invading the serous cavities also. Other organs will enter in as 
complications, so we may see nausea, vomiting, diarrhea, or bron- 
chitis and pleuritis, or nervous symptoms in the form of nervous 
headaches, or a true uremic condition. On account of the weakness of 
the heart or other complications the patient is liable to die. Yet in 
most cases, under a well-directed treatment, the symptoms subside and 
the patient may recover. Relapses of acute nephritis may occur, just 
as an acute form may terminate in chronic nephritis. 

In the chonic diffused nephritis, on account of the obscurity of 
their etiological moments, it is not so easy to recognize the syphilitic 
origin, because the symptoms have nothing characteristic, and the 
diagnosis will be based solely either on the history of syphilis or on 
the accompanying syphilitic symptoms. Not even is the microscopic 
examination capable of revealing syphilitic chronic nephritis, because 
the alterations of arterio-sclerosis and of amyloid degenerations are 
the same as those found in subacute mercurial nephritis, revealed by 
necrosis and calcification of the epithelium, glomerulitis with edema, 
and infiltration between the canaliculi. In the same way we must also 
take under consideration a certain degree of alcoholism, which is quite 
often the cause of chronic nephritis. 

We can, therefore, state that a chronic diffused nephritis has no 
characteristic point to be referred to syphilis, such as we see in an 
acute nephritis, on account of the multiplicity of causes and of the 
slight difference between them. In most cases, it seems that the gen- 
eral specific treatment, especially in the first year, had been greatly 



CONSTITUTIONAL SYPHILIS 83 

neglected. Nearly all the cases had shown symptoms of a tertiary 
nature in the skin, bones, periosteum, nervous system, etc. Its ap- 
pearance at a late date, its tendency to attack the whole organ, its 
alterations of a degenerative nature, point it out as being syphilitic 
nephritis of a toxic origin. 

As a consequence, characteristic symptoms of syphilitic nephritis 
do not exist, and under the circumstances we must follow the advice 
of Gubler. When a patient shows all the symptoms of a nephritis, 
either acute or chronic, and the etiology is doubtful, it is necessary 
to think of the possibility of syphilis and begin a specific treatment. 
If the patient shows signs of syphilis on the skin or in other organs, 
this will confirm the diagnosis of syphilitic nephritis. We must not 
forget, however, that an old syphilitic is also liable, independently of 
syphilis, to get an ordinary nephritis from any other cause. 

The yielding of the disease to the specific treatment will be, in 
these cases, a good argument in favor of a syphilitic affection. 

The kidney is also the seat of the gummata. Virchow had found 
in the kidneys partial, circumscribed cicatrices, which he regarded as 
the result of the reabsorption of a syphiloma, but a true gumma he 
did not find. Lancereaux found the syphiloma of the kidney which 
he described in his " Traite de la Syphilis." 

Gummata of the kidneys is a very rare occurrence, unless the 
partial cicatrical condition sometimes found in the kidney is considered 
as the result of gummata. They appear in the kidney in the form 
of round tumors, from the size of a lentil to that of a cherry. In 
some cases they are superficial in the cortical portion, sometimes they 
are also deep in the substance of the organ. They look like nodules 
or partial elevations, pale in color, and the kidney is considerably 
enlarged. They undergo the changes which we have already men- 
tioned for the contents of the gumma, while the edges become hard 
and fibrous. At times the gumma may be in the form of a diffused 
infiltration, which causes the tissues to fall into a necrotic condition. 
The symptoms of a gummatous nephritis are different according to 
the stage of the gumma, and the albuminuria and the presence of 
casts is not constant. It may be that if the gumma affects only one 
kidney, its function is entirely impaired, while the other kidney con- 
tinues to segregate normal urine. A localized tenderness in one of 
the kidneys may suggest the idea of the presence of a unilateral 
gummatous nephritis, especially if this is accompanied by a variable 
quantity of albumen and different casts. 

Syphilitic affections of the kidneys in the form of acute nephritis 
in the beginning- of the constitutional syphilis, runs, as a rule, a 
favorable course. In severe cases also, when the diagnosis has been 



84 THE MEDICAL ASPECTS 

established early and an antisyphilitic treatment has been started, a 
favorable change may be expected. Even in the gummata of the 
kidney a favorable prognosis may be advanced, for the reason that, 
in these cases, a large part of the parenchyma of the kidney is left 
untouched, and this part continues to perform its function. If the 
affection is limited to one of the kidneys, the outcome is still more 
favorable, because the healthy one will compensate the loss of function 
in the other. Syphilis has been pointed out by v. Frerichs as one of 
the principal causes producing diabetes, very likely on account of the 
luetic alterations occurring in the brain, meninges and medulla ob- 
longata. Other clinicians, however, reject this opinion and maintain 
the view that if diabetes has been found in a syphilitic, it has only 
been a mere coincidence. Another cause capable of inducing glyco- 
suria and polyuria is the use of mercurials, some of which have a 
decided diuretic action, increasing the quantity of the urine. 

SYPHILIS OF THE MALE GENITO-URINARY ORGANS 

In our brief examination of the urinary organs affected by syphilis, 
we find the urethra also deserves special consideration. The occurrence 
of the initial lesion in the urethra has been already mentioned. It 
usually affects the meatus, and the fossa navicularis, but in the deeper 
portions of the urethra it is a rarity. In the secondary period Lang 
relates that he found through endoscopic examinations, red patches 
in the mucous membrane of the urethra, somewhat swollen, at times. 
with erosion, coincident with a papular eruption of the whole body. 
Later forms of syphilis are more frequently found. In our practice we 
have found an ulcer in the urethra, extending from the meatus down to 
the pars pendula, with a thick infiltration, which had been treated with 
every kind of remedy except the antisyphilitic. This yielded very 
easily to the general and local specific treatment. Proksch described 
ulcerations of the bladder, and Virchow found an ulcer in the bladder 
of an old syphilitic woman. Syphilitic gummata of the urethra have 
often been found and in our hospital practice, especially amongst 
colored people, we have seen gumma of the fossa navicularis, which has 
broken down and produced urethral fistula in that region. As a con- 
sequence of gumma of the corpora cavernosa, deformities of the penis 
have resulted. In a case resulting from an ulcerated gumma of the 
urethra the patient suffered a heavy hemorrhage, for which he was 
taken to the hospital. 

In the article concerning the modes of infection we have alreadv 
spoken of the frequency with which the initial lesion affects the penis 
in its different parts. In the same way we have pointed out the 



CONSTITUTIONAL SYPHILIS 85 

different roseolar and papular eruptions showing in the penis as on 
the other parts of the body. Mucous patches often make their ap- 
pearance between the sulco balano preputiale in all their different 
forms. 

Late syphilitic lesions in the form of gummata are quite frequently 
met with on the penis. Small indolent gummata from the size of a 
lentil to that of a bean are found in the glans and also in the corpora 
cavernosa. We have quite frequently seen small gummata on the 
glans, which had broken down and produced an ulcer, giving to the 
patient the idea of a new chancre. Gummata of the corpora cavernosa 
are more rarely found ; sometimes they may undergo reabsorption 
and disappear, leaving a hard callosity at its place, but it can also 
break down, cause ulceration and perforate the urethra. 

We have not infrequently found g-angrene of the penis as the 
result of an infiltrated gumma. In one case it produced the spon- 
taneous amputation of the glans, leaving the urethra sticking out. In 
the hospital service we have had occasion to see several cases of 
gangrene coming at once without any traumatic cause, with acute 
pain in the whole penis, redness, swelling and edema extending to 
the pubis, together with phimosis. When we have opened the prepuce 
we have found the glans black and affected with humid gangrene. 
The death of the affected tissues stopped towards the sulcus balano 
preputiale, sloughed out in a week or so and then the process of 
reparation began. All our patients had suffered syphilis at a late 
stage, and the gangrene of the penis was the result of a gangrenous 
gumma. It is scarcely necessary to mention that the penis has re- 
mained mutilated, and deformities have been the result. 

Syphilis, especially at a late period, frequently affects the testicle. 
The syphilitic affection may be limited to the epididymus, to the 
testicle, to the vaginalis, or may affect the whole apparatus in the 
form of a simple inflammatory process. It is also found to invade 
the testicle in a gummatous form. Drou 21 of Lyons called attention 
to the presence of epididymitis in secondary syphilis, which was after 
a while confirmed by Tanturri and Fournier. 

The affection makes its appearance at the secondary stage in the 
form of an indurated point at the head of the epididymus, of the size 
of a bean or a hazelnut ; in some cases it is indolent, though usually 
it is accompanied by acute pain and tenderness. The inflammation 
spreads to the neighboring structures of the testicle and cord, which 
are involved together with the epididymus. The tunica vaginalis is 
also involved, and Jullien 22 referred to a case where there was an 

21 Drou. Arch, de Med., 6 ser, tome II, 1863. 

22 Tullien. " Malad. veneriennes." Paris, 1886. 



86 THE MEDICAL ASPECTS 

abundant hydrocele. Keyes has found six and Fuller 23 two cases, in 
which an extensive induration of the epididymus and of the testis was 
accompanied by considerable hydrocele. 

Oelsnitz 24 and Ozenne 25 have published articles on syphilitic 
pachyvaginalitis and from the fact that in the serum there has been 
found some blood, Ozenne has called it hemorrhagic pachyvaginal- 
itis of syphilitic origin. In our practice not rarely have we met with 
cases of this kind. We remember a young man who had suffered a 
rather severe case of syphilis for over two years, who began to com- 
plain of a swollen testicle, which had gradually reached an enormous 
size. It was uneven, the epididymus could not be distinguished from 
the testis. It was a uniform mass, elongated in the shape of a sausage, 
extending to the spermatic cord. On account of the undulating sen- 
sation produced by the serum, it was tapped, but only a small quantity 
of brownish bloody serum came out. Under a regular mixed treat- 
ment the enlargement of the testis gradually diminished and returned 
to its normal limits. 

In simple orchitis, a chronic indurating infiltration arises from the 
albuginea, sometimes from the septa and from the connective tissues 
which surround the seminal ducts. It affects larger or smaller por- 
tions of the testicle ; causing at first an enlargement, and later a con- 
traction of the organ. When the process is equally diffused, the 
surface of the testicle is smooth, but it usually is limited to different 
parts forming nodules, which later are converted into depressions. 
According to the seat of the infiltration, either in the albuginea or in 
the interior of the testis, we speak of orchitis or periorchitis. The 
tunica vaginalis is also thickened and contains exudation. Gum- 
matous products are also combined with orchitis, and in the con- 
necting tissues infiltrating nodules are found, which may undergo 
reabsorption, or are found calcified or in cheesy degeneration. 

Clinically the syphilitic orchitis, especially if it comes a few 
months after the infection, may be bilateral ; it is accompanied by 
little pain and the swelling is diffused over the testicles together with 
the epididymus. Usually syphilitic orchitis is a late manifestation of 
syphilis ; the enlargement of the testicle takes place slowly, being 
accompanied by a slight pain and a sense of weight in the scrotum. 
The surface of the testicle is uneven, for the reason that the affection 
results from nodules disseminated in the substance of the gland. 
Sometimes, when the vaginalis propria is involved, there is some 

23 " A System of Genito-Urin. Diseases." Edited bv Prince A. Morrow, 
1893. 

24 0elnitz, A. "These de Paris." 1886. 

25 Ozenne. Gas. Hcbdom. dc Med. 1882, 2 ser. xxv. 






CONSTITUTIONAL SYPHILIS 87 

effusion, and when the affection is near the epididymus, this also 
is involved in the process. , 

Gumma of the testicle but rarely suppurates ; it is usually reab- 
sorbed, producing sclerosis and contraction of the affected tissues. 
In consequence, the segregating part of the gland rarely escapes de- 
struction, causing diminution of the spermatic secretion, or even total 
aspermia, with a lack of desire for sexual relation or total impotence. 

After many months the testicle gradually diminishes in size, its 
shape is usually preserved, remaining sometimes smooth, at other 
times uneven with depressions. In some cases it is reduced to a 
shapeless rudiment of the testicle. 

The general condition of the patient is not involved with the 
affection of the testicle, on account of its indolent course, but it 
usually produces a great depression of mind when it is known that the 
organ of generation has been attacked. We have seen patients affected 
with syphilitic orchitis who complained of obstinate insomnia, caused 
by the gloomy thought of remaining impotent. 

In rare cases the gummatous infiltration of the testicle forms a 
tumor involving all the coverings of the testicle, comprehending the 
skin, which softens and will perforate. In this case the gumma grows 
exuberantly in the form of a granular mass, which has been named 
fungus testiculi syphiliticus. It is usually accompanied, in the begin- 
ning, by a pain, which gradually subsides. It takes on the appear- 
ance of a fleshy tumor sticking out of the skin, narrowed at its base, 
red and cyanotic, exuding pus and covered with necrotic detritus. The 
fungus of the testicle lasts for some time, gradually becoming smaller, 
partly by absorption, mostly by sloughing of the necrotic parts. This 
process takes a long time. The prolonged suppuration and resulting 
fever greatly weaken the patient, and the cicatrization follows accord- 
ing to the treatment. 

Syphilitic affections of the testicle, when making their appearance 
at a late period of syphilis, are usually accompanied by gummatous 
lesions in other parts of the body. In our practice we have, at present, 
a patient affected with syphilitic orchitis of the left side, who has at 
the same time a periosteal gumma of the internal malleolar region. 

In other cases deep syphilitic lesions have already healed up and 
the presence of the scars will be a valuable help for establishing the 
diagnosis of syphilitic orchitis. There are, however, cases of syphilitic 
orchitis which make their appearance without deep lesions having 
taken place, and when the enlargement of the glands had somewhat 
subsided. In these cases some doubt may arise as to the nature of 
the affection. 

No difficulty may be found in diagnosticating between a gonor- 



88 THE MEDICAL ASPECTS 

rheal affection and a syphilitic orchitis. In the first the symptoms are of 
an acute inflammatory nature, affecting mainly the epididymis, with 
swelling accompanied by an excessive pain and with some exudation in 
the vaginalis. The spermatic cord is also involved, and the scrotum 
on the affected side appears red, tender and swollen. There will be 
found some discharge from the urethra, or the patient will admit that 
it was present for a time and that it ceased at the time of the inflam- 
matory attack. In syphilitic orchitis the affection makes its appearance 
without pain, being indicated only by the swelling of the testicle, pro- 
ducing only a sense of weight. The epididymus cannot be distinguished 
from the testicle, as it forms a mass which is uneven to the touch on 
account of the nodules which are formed on the testicle. 

There may be some difficulty in cases of tuberculosis, which often 
affects the epididymus. It affects this organ in several foci of infiltra- 
tion, independently of each other, from the size of a split-pea to that 
of a walnut, firm to the touch, but becoming soft in a few weeks. 
The skin is bluish red in color, forming small prominences which 
break down and give issue to a quantity of pus. It leaves a fistula, 
which leads through a tortuous path to the place of infiltration. From 
the fistula a thin pus exudes, which may sometimes contain tubercle 
bacilli. It heals up now and then and in a short time opens again, 
discharging the accumulated pus. The process is accompanied by 
fever, especially in the evening, and the patient becomes weak on 
account of the continuous suppuration. The tubercular foci affect the 
testicle also and in this case the condition of the patient is still worse. 
The individual foci on the testicle are not easily found, unless the 
skin has been ulcerated, and the perforation taken place. The skin 
of the scrotum is tense over an enlarged testicle and studded with 
ulcers covered with necrotic shreds of tissues or showing red, " proud," 
granulations. In the testicle can be found soft points corresponding 
with the suppurating foci. Tuberculosis of the testicle is usually 
accompanied by other symptoms of tuberculosis, especially of the 
lungs. There will be no difficulty in differentiating a syphilitic orchitis 
from a tubercular testis when we take under consideration the seat of 
the affection, which is the epididymis in tuberculosis, the purulent 
disintegration of the infiltrated foci, and the possible presence of the 
tubercle bacilli. 

Syphilitic affections "of the vas deferens have been reported by 
Zeissl in the form of a suppurating infiltration of the organ, and by 
Bert in the form of nodules. Very few observations have been made 
in reference to the seminal vesicles and to the prostatic gland. 

There is no doubt that the semen is affected by syphilitic virus, 
and the fact of the transmission of syphilis to the offspring is a valid 



CONSTITUTIONAL SYPHILIS 89 

proof that the poisonous germs are carried in the semen. It seems 
that the syphilitic germ directly affects the spermatozoa, which entering 
into the ovum, infect it at the time of fecundation. This is the 
paternal heredity, which appears clearly in the cases where a mother 
free from syphilis gives birth to a syphilitic child, and receives the 
infection from her syphilitic babe. 

The infectious qualities of syphilis are preserved in the semen 
much longer than in the other fluids of the organism, so that, when 
syphilis has ceased to be transmittible by the ordinary ways, the semen 
still maintains the property of infecting the offspring, and through it, 
of communicating the disease to the mother. 

The testicles are often the seat of syphilitic affections. Severe 
forms are, however, found only at a late period. Impairment of 
their functions and destruction of the organs occur, with resulting 
impotence, at the late stage of lues. 

SYPHILIS OF THE FEMALE GENITO-URINARY ORGANS 

From their anatomical structure it can be seen how easily they 
can be inoculated with syphilitic virus, and present the initial lesion 
in almost any part from the labia majora to the cervix of the womb. 
If local infection from the semen be admitted, then we should assume 
the possibility of an initial lesion in the cavity of the uterus and in the 
tubes. 

The external genitals of the woman are favorite places for the 
eruption of mucous patches, which appear on the labia majora and 
minora, on the ostium vaginae, and are the most dangerous lesions for 
the transmission of syphilis. Papules in the vagina are of rare occur- 
rence and are more often found on the cervix. Virchow spoke of a 
papular endometritis which he observed in the post-mortem of corpses 
of individuals who had suffered with severe syphilis. 

Gummata on the external genitals of the woman are frequently 
found, usually in an ulcerated condition, but rarely on the organs of 
generation. In fact, we have so far no report of gummata of the 
body of the uterus. Bouchard and Lepine have each reported a case 
of three gummatous nodules of the size of a hazel-nut, in the tubes 
of a woman who had gummata of the brain and of the liver. 

The ovaries are subject to syphilitic affections in the form of 
diffused or gummatous oophoritis. Diffused oophoritis has been recog- 
nized in the bodies of women who had not yet reached the menopause, 
and was recognized by the shrunken condition of these organs, which 
had become fibrous, showing cicatricial points, without the follicles 
of Graaf. 



90 



THE MEDICAL ASPECTS 



It is not necessary to state that syphilitic affections of the uterus, 
tubes and ovaries have a great influence upon the development of the 
fetus, which usually dies in utero. In the same way cicatricial points 
in the substance of the uterus may at the time of delivery produce 
some difficulties during labor. 

SYPHILITIC AFFECTIONS OF THE BONES AND JOINTS 

The bones are especially subject to syphilitic lesions of a gum- 
matous nature ; in fact, gummata were first recognized and studied in 
the bones and in the periosteum. The alterations of the bones conse- 
quent to the syphilitic affections are of a deep character, and they 
usually remain through life, to witness the existence of syphilis. 
Furthermore, syphilis produces anemia and induces a lymphoid change 
in the marrow of the bone. 

The prolonged suppuration of the bone seems to be one of the 
most effective causes in syphilis, as well as in tuberculosis, in produc- 
ing amyloid degeneration of important organs. 

In the course of syphilis, affections of the periosteum occur quite 
frequently in the form of a simple irritative periostitis, and later on 
they may be associated with gummatous infiltration. 

Simple periostitis is the result of an hyperemia with increased 
vascularity, which, lasting some time, causes alterations of nutrition 
in the connective tissue fibers, revealed by swelling and tenderness. 
The periosteum is thickened sometimes in circumscribed areas, at other 
times on a diffused surface. An infiltration is formed between the 
bone and the periosteum, which, loose at first, remains later on inti- 
mately attached, and after undergoing involution is ossified, molding 
itself exactly on the bone, and so there remains that peculiar roughness 
of the bones, especially of the tibia, which will last all the life long to 
witness to the existence of an old syphilis. 

In other cases the accumulated infiltration is much circumscribed 
and forms a growth of osteophytic formation, which has been described 
by Fallopius under the name of tophi. Under an appropriate treat- 
ment they may disappear if the absorption begins before the ossifica- 
tion of the periosteal product. In some cases when the individual is 
badly nourished or affected with tuberculosis, the infiltration may 
undergo disintegration and end in suppuration, which may cause 
caries and necrosis of the superficial layer of the bone. 

We find this affection in the form of an elastic, soft periosteal 
swelling, arising from the inner surface of the periosteum, involving 
at the same time the bone. It causes a depression on the bone corre- 
sponding to the gummatous swelling, but at the base and the periphery 
of the gumma it shows a certain degree of hyperostosis. 



CONSTITUTIONAL SYPHILIS 91 

When the gumma undergoes fatty degeneration it is reabsorbed, 
leaving* a limited depression on the bone, the result of the loss of sub- 
stance. The edges, however, will remain hard and prominent on 
account of the new bony formation. The periosteal gumma may be- 
come liquefied and cause caries and necrosis of the bone. In this 
case the contents find their way under the skin, which is inflamed, 
forms an abscess, and breaking down, gives issue to purulent and 
cheesy matter, sometimes leaving sinuses in connection with the dis- 
eased bone. 

In the same way as we have done for the periosteum we must 
distinguish for the bone a simple .irritative osteitis and osteomyelitis, 
and a gummatous osteitis and osteomyelitis, where we find the infiltrat- 
ing character of the gummatous process. 

Specific osteitis is not different from a non-specific ; it shows at 
first as a rarefying osteitis, and then when the reabsorption takes place 
it becomes a formative osteitis. The disease begins in the soft tissues 
around the blood vessels, causing an enlargement of the Haversian 
canals, and consequently the erosion of the superficial layer of the bone 
ending in partial necrosis. The cells contained in the Haversian canals 
in the diseased bone take on a certain degree of development, as in 
the embryonal stage, and as a result of their pressure on the tissue of 
the bone produce absorption of the osseous tissue. The lamellae of 
the bone are eroded and the bone corpuscles open and the cells con- 
tained therein are set free, and, in this way, they may join the em- 
bryonary cells in the medullary spaces. It seems that from the en- 
largement of the bone corpuscles, a solution of area of the osseous 
substance is produced, with the final result of their fatty degeneration 
and absorption. 

This process of rarefying osteitis is usually limited, but sometimes 
may affect the whole surface of a flat bone. So long as the irritation 
continues, there is no attempt to repair, the tissues are more and more 
eroded, and the detritus is carried away in the purulent secretion, or 
remains as a dead product in the form of a sequestrum surrounded by 
granulation tissue. 

In consequence of treatment, when the discharge is free and the 
irritation has ceased, the bone begins to repair through a formative 
osteitis. In this process a new bone is produced either beneath the 
periosteum, or in the substance of the bone, or in the medullary canal. 
The deposits of new bone on the surface are called osteophytes when 
small, or nodes and exostoses when larger, and when affecting the 
whole length of the bone, hyperostosis. When the new bone is found 
in the medullary canal it is termed enostosis. The new bone is dis- 
tinguished from the old bv the different direction of their blood vessels 



92 THE MEDICAL ASPECTS 

and of their trabecular, which run perpendicular to the surface. This 
is due to the fact that the osteoperiosteal vessels in the new bone have 
origin from the Haversian canals on the surface of the bone, and 
around these the new lamellae are formed, which produce the ossifica- 
tion from the elements of the embryonal tissue. 

The new trabecular are the production of the embryonal cells, 
which we saw were the result of the rarefying osteitis. They are 
usually disposed around the edges, where the process of reparation 
takes place, forming new bone around the existing depressions. This 
causes irregularities on the surface of the bone. 

When cavities have been produced in the bone near the medullary 
canal, new bone may be produced in a similar manner as on its surface. 
When a sequestrum has been formed it remains imbedded in the new 
bone ; it may cause repeated attacks of osteitis until it is removed. 

Formative osteitis, when involving the substance of the bone, 
leads to its sclerosis or hardening, a process which is known as eburna- 
tion or condensing osteitis. In this case the new bone is very dense 
and has a consistency like that of ivory. When it occurs under the 
periosteum, the condensing osteitis may affect the bone in parts or its 
whole extension. When in the medullary canal, proliferation of the 
bone tissue may take place to such an extent as to obliterate it entirely. 
In some rare cases eburnation of the bones takes place on their sur- 
face, while the interior is eroded by the rarefying osteitis. The con- 
densed bone forms the support of the shaft, which would otherwise 
easily break. 

A rarefying and formative osteitis often changes the shape of the 
bone, especially towards the joints. In children, on account of this 
peculiar process of inflammation, there may be a detachment of the 
epiphysis from the diaphysis, leading to a pseudo-paralysis. W Tien the 
condensing osteitis is active, premature ossification of the bones of the 
skull may occur with resulting cranial asymmetry and malformation. 

The new bone may produce a pressure on the Haversian canals 
so as to cut off the blood supply from other parts of the bone, causing 
them to fall into necrosis. It is soon surrounded by numerous granu- 
lations, the result of the rarefying osteitis, which is an effort of nature 
to get rid of the necrotised part called sequestrum. If this is seated 
on the surface of the bone, it is soon separated and carried away with 
the purulent discharge. But when it is deeply seated in the substance 
of the bone, it acts as a foreign body, maintains a constant irritation 
causing abscesses and sinuses, until it is entirely removed. 

Gummatous infiltrations occupying the bony tissue are capable of 
causing necrosis by cutting off the nutrition from the bone. The 
sequestrum has an appearance as if it were worm-eaten, being traversed 



CONSTITUTIONAL SYPHILIS 93 

by small channels and holes, while the sequestrum from other causes 
appears smooth and equal. The gummatous deposits penetrate into 
the substance of the bone, leaving marks of their destruction. After 
the sequestrum has been removed the loss of substance is imperfectly 
repaired, leaving inequalities on the surface of the bone. 

In some cases caries and necrosis of the bone may be the result 
of ulceration of the skin or of the mucous membrane. The dis- 
integration of the soft parts reaches the bone, which is denuded and 
is affected with superficial necrosis. We have already considered the 
destruction of the bones of the nose and of the palate, in consequence 
of gummata affecting the mucous membrane of these parts, which, 
breaking down, involve the bone in the process of disintegration, pro- 
ducing perforations and destruction. 

There has been attributed to syphilis another condition of the 
whole osseous tissue, whereby the bones become of such a fragil- 
ity that any forcible effort may break them. It has been called 
osteopsathyrosis, fragilitas ossiiim, which is especially found in the 
long bones. According to Charay the resistance of the bones must be 
diminished at least fifty per cent., and the resulting fragility must be 
caused by a marked decrease of fluoride of calcium. The whole affec- 
tion must be the result of the syphilitic cachexia, from the lowered 
nutrition of the general system, which also extends to the bones. 

An irritative form of periostitis is revealed by diffuse swelling of 
the periosteum, accompanied by dull pains, which are usually more 
intense at night. The patient's general nutrition is usually well main- 
tained and, in spite of his pains, he is still able to go about. We find 
this condition quite often in the tibiae and in the bones of the skull. 
Under an appropriate treatment the inflammation subsides, the exuda- 
tion is easily reabsorbed, and the pains gradually cease. But when 
the swelling remains there is reason for believing the possibility of the 
ossification of the periosteal products. 

In cases where periostitis ends in suppuration the pain is still 
more severe. The inflammatory swelling is painful and tender to the 
touch. The skin covering the area becomes red, edematous, and 
gradually assumes a bluish color, and at the highest point of its con- 
vexity is greatly reduced in thickness. The pressure of the pus per- 
forates the periosteum, and consequently the skin, giving issue to a 
thick, dark yellowish pus. The pains then diminish and also cease 
entirely when there is a good drainage opened. On introducing a 
probe we find that the bone is detached from the periosteum and with- 
out any roughness. If no complications arise, the periosteum may 
again be attached to the bone by means of granulations, and leave very 
few traces of the process. In the places where the periosteum has 



94 THE MEDICAL ASPECTS 

been ulcerated the granulation coming from the bone may form a 
cicatrix involving all the tissues, leaving the skin adherent to the deep 
tissues. 

In cases of gummatous periostitis the infiltration is more circum- 
scribed, and the accompanying pains are much more intense. The 
gumma is felt as a firm nodule in the beginning, but becomes soft 
later on, and when liquefaction takes place, may cause a sensation of 
fluctuation. The skin is somewhat raised by the gumma, and only 
when the disease is advanced does it take on a brown red color, which 
lasts for a long time if the gumma undergoes absorption. In case the 
gumma is liquefied and a necrotic process takes place, the skin is then 
involved ; it is swollen, has a deep bluish red color, and at the point 
of pressure is gradually perforated. The result is an ulcer with a deep 
bottom covered with a large quantity of necrotized tissue, and with 
thick and deeply infiltrated edges. The process of disintegration of 
the gummatous infiltration is a slow one, and begins in the center and 
extends to the periphery. For this reason, while the center of the 
periosteal gumma is broken down, the edges are still thick, infiltrated 
and swollen. The ulcer begins to heal up only when the peripheral 
portion of the gumma is destroyed, then the swelling goes down, the 
surface is covered with healthy granulation and heals up in a short 
time. In the periosteal gumma, the bone is also involved, and in 
both cases, whether the gumma undergoes reabsorption or disintegra- 
tion, the bone is damaged by the process, and will have a depression 
in the place where the gumma has been. This depression left by the 
periosteal gumma is made more perceptible by the morbid ossification 
of the infiltration along the edges, which makes the surface of the 
bone rough and irregular. 

If it is easy to make the diagnosis of periostitis, it is not so easy 
to establish the diagnosis of osteitis and osteomyelitis. The process 
begins with dull pains in the deeper parts which are subject to exacer- 
bations towards evening. Mild fever may be present, but this is not 
usually the case. The bone does not show any objective symptoms, 
and its changes are not shown until very late. The diagnosis will, 
therefore, rest on the continuous and even increasing pains, and the 
absence of perceptible alterations of the bone. In case of sclerosis of 
the bone as a consequence of osteitis, the patient will complain of a 
peculiar heavy feeling of the limb, which may interfere with its 
functions. 

Osteitis is subject to the reabsorption, and only very rarely may 
end in an abscess. 

Gummatous osteitis and osteomyelitis run their course in an 
obscure way. Osteocopic pains are present in some cases, but in others 



CONSTITUTIONAL SYPHILIS 



95 



they are absent. By means of palpation or by gentle percussion, we 
find limited tender spots in the tibiae or in the skull, which makes us 
suspect the presence of osteitic affection. A gummatous osteitis, 
however, is usually accompanied by localized pain, increasing after 
some exertion, and more intense at night. In some cases the peri- 
osteum and the surrounding tissues are involved, and then the affected 
place is shown by marked swelling and tenderness. In other cases 
the gummatous process dilates and distends the osseous tissue, causing 
an increase in the size and a change of the shape of the bone, which 
in the phalanx was called spina reutosa. The bone is light and porous, 
in some cases it is reduced to a shell (osteoporosis), and in this condi- 
tion may easily be fractured. 

The gummatous infiltration, as a rule, undergoes absorption under 
proper treatment, while the swelling and the other symptoms gradually 
disappear. The rarefied bone is compensated by the formative ostetitis 
and in this way there are found areas of greater density surrounding 
the affected places. When the rarefaction in the bone has been of a 
certain extension, it may, after the healing of the gumma, remain 
somewhat fragile and liable to suffer spontaneous fracture. In some 
cases the loss of bone after the reabsorption of the gumma can be seen 
in the phalanges, which remain shortened and half mutilated. 

The gummatous process undergoes disintegration, producing 
necrosis of the bone accompanied by suppuration. When the pus is 
retained in the sinuses under the periosteum it causes pain, and it may 
bring about an attack of erysipelas, lymphangitis, etc. When the pus 
has free drainage, the pain is very slight. The pus is of foul odor, 
mixed with the necrotized particles of the bone, and suppuration con- 
tinues until the dead bone has been removed. 

The bones can be attacked at any time during the evolution of 
syphilis, and in some cases we find symptoms in the osseous system 
at the early period of constitutional syphilis. Every bone of the body 
is liable to be affected by this disease, and Dittrich referred to a case 
of caries and necrosis of the hyoid bone in a female day laborer, thirty- 
one years of age, who had also other symptoms of syphilis. 

In the line of frequency we find that the bones of the skull are 
frequently attacked by syphilis, the frontal and the parietal bones 
much oftener than the occipital and the temporal bones. The nasal 
bones and those forming the hard palate are often perforated and 
damaged by syphilitic affections. 

The long bones are also affected, especially the tibia and the 
fibula, the radius and the ulna ; while the humerus and the femur are 
only rarely involved. The clavicles are often found affected with 
periostitis and osteitis, and their sternal extremity remains thickened 



96 THE MEDICAL ASPECTS 

and tender, this alone giving good ground for the diagnosis of syphilis, 
The ribs are also affected by syphilis, while the vertebrae are usually 
spared. When the epiphysis of the bones is affected with gumma the 
process may spread to the joint. The bones most frequently attacked 
are those which are most superficial, and, in consequence, most exposed 
to external injuries. In fact, the patients often speak of an injury 
causing the affection, and it is not entirely out of the range of possibility 
that the syphilitic virus affects the places where an irritation has 
already been produced. 

Although syphilis apparently does not interfere with the healing of 
wounds, yet observations indicate that it may retard the formation of 
the callus in a fracture of the bones. The failure of the fractured 
bones to reunite must be due in all probability to a gummatous deposit 
at the point of fracture. Lang refers to cases of imperfect reunion 
of fractured bones in syphilitics which became perfect after a good 
constitutional treatment had been given. 

It is well known that the affections of the bones have been con- 
sidered by the antimercurialists as produced by mercury. It was the 
popular belief that mercury would accumulate in the bones and, by its 
expansion, caused by the rising of the temperature, produce the 
osteocopic pains. It is not necessary to say that this is a simple 
prejudice without any foundation. We have found affections of the 
bones in syphilitic individuals who had received no mercurial treatment 
whatever, and we see in our ordinary practice that mercury alone 
cures the affections of the osseous system. In our practice we meet 
every day with cases of osteitis and periostitis in individuals who have 
had no mercurial treatment at all, or at least an insufficient one. 

The affections of the bones have an exceedingly slow course. It 
takes months and even years to see the end of these syphilitic attacks. 
In some cases gummatous foci are successively repeated, thus pro- 
longing the existence of the disease. 

Syphilitic osteitis and periostitis are not always painful, and with 
the exception of some paleness and decreased nutrition they do not 
cause grave functional disturbances. The pain seems to be the result 
of acute swelling of the periosteum and of subperiosteal exudation. 
In some cases of osteitis, without marked swelling, there has been 
found extreme tenderness in the bones. 

The pain accompanying syphilitic affections of the bones has 
been described as boring, beating or sawing, or as tearing, dragging, 
or representing any other heavy, torturing sensation. The pains are 
more intense at night than in the daytime, so much so that they prevent 
the patient from sleeping. It seems that the heat of the bed, the hori- 
zontal position, and probably the attention of the patient drawn con- 



CONSTITUTIONAL SYPHILIS 97 

stantly to the locality of the pain, make the pains appear much more 
intense at night. It has been observed in cases where the patient, on 
account of his occupation, was working at night and sleeping in the 
daytime, that he did not notice pains while working, and the pains 
prevented him from sleeping' as soon as he lay down in bed in the 
morning. 

When the bones of the skull are affected, if the process is limited 
to the periosteum, the affection remains local and without serious con- 
sequences ; but if the process has its seat in the internal surface of the 
bone, it may, by compressing the brain, become the origin of serious 
nervous disorders. 

Gummatous osteitis producing necrosis is one of the gravest 
occurrences. On the skull it may run a latent course, but the soft 
parts are usually involved to a certain extent, and the necrotized bone 
appears as a blackened mass. If the process has involved the whole 
bone, then the sequestrum may be detached and a hole is made in the 
skull, -leaving the brain covered only by the meninges. Even such 
grave destructions are repaired by nature; a strong and heavy cicatri- 
cial tissue is capable of covering the destruction and leaving a thick 
cicatricial depression, where the pulsation of the brain can still be 
perceived. 

Cases of osteitis with necrosis of the bones of the skull must be 
treated with local and general treatment, but as far as surgical inter- 
ference is concerned, it is better to leave it to nature, which is capable 
of throwing off a sequestrum without assistance, and of limiting the 
process to the least destruction. It is not so in those cases compli- 
cated with severe cerebral symptoms, when syphilitic bony produc- 
tions cause a pressure on the brain. There are cases on record where, 
by the timely removal of a portion of sequestrum, the patient's life has 
been saved by the removing of the pressure on the brain produced by 
the necrotized bone and by an accumulation of pus. 

Cases of this kind, however, are very rare, because the syphilitic 
process fortunately limits itself to the superficial surface of the bones, 
which can be reached with therapeutic means. 

We can only refer to one case of periostitis of the orbital bones, 
which ended with an abscess in the inferior segment of the orbit. The 
individual had contracted syphilis some eight years before the affection 
of the orbital region developed, and for some months he complained of 
neuralgia of that region. The eye protruded somewhat, and was 
pushed upwards, fixed, and entirely immovable. A large swelling 
was made out underneath the eye-ball, which revealed the presence of 
pus. The abscess was opened, the pus evacuated, the cavity was 
packed was iodoform gauze, and recovery was the final result. 



98 THE MEDICAL ASPECTS 

Cases of the same kind have been reported, one by Ferdinand 
Schott and Soloweitschick, the patient dying with meningitis; another 
by R. Campana, where the abscess opened externally and the case 
ended in recovery. 

The bones forming the base of the cranium can be affected by the 
diseased condition of the nasal or pharyngeal cavity. Fortunately 
the occurrence is a very rare one. In the same way affections of the 
temporal bones by syphilis have been very seldom met with. 

The bones of the face are also affected by the syphilitic process, 
and we have already spoken of the frequency of these attacks on the 
nasal bones of the septum of the turbinates, etc. ; but the maxillary 
superior, the zygomatic arch have sometimes been affected with peri- 
ostitis and osteitis. 

Syphilitic affections of the spinal column have been referred to 
by John Hunter. The cervical region of the spinal column is more 
frequently attacked. Lang reported a case of periosteal enlargement 
developed on the anterior surface of the cervical spine, in a man after 
nearly one year from the infection. He also reported another case 
of syphilitic caries of the cervical vertebrae resulting from gummatous 
osteitis, which could be demonstrated through a sinus opened in the 
posterior wall of the pharynx in a man eight years after the infection. 

Observations of syphilitic affections of the dorsal and lumbar 
spinal column are very rare. 

Affections of the fingers from syphilis are quite frequently found, 
and they are so characteristic that A. Lucke applied to them the name 
of syphilitic dactylitis. It affects the fingers and the toes in the form 
of a gummatous infiltration, but it is oftener the former than the 
latter which are attacked. It is found in cases of acquired as well 
as in cases of hereditary syphilis, but is more frequently a lesion of 
hereditary syphilitic taint. 

Two varieties of this disease have been described : one where the 
affection involves at first the fibrous structures of the joint; another, 
where the periosteum and the bone are at first affected and the joint 
is attacked only secondarily. 

When the bones of the phalanges are affected, soon the periosteum 
and the soft parts of the fingers are involved. The phalanges are 
swollen to twice the normal size, puffed up in the middle in a round 
shape, covered by a shining, smooth bluish white skin, which is not 
movable over the tissues underneath. The bone is greatly increased 
in thickness, and its enlargement is due to a periostitis or to an 
osteitis, which causes the swelling of the cortex of the bone. Usually 
the gummatous infiltration is reabsorbed and the swelling gradually 
diminishes, and everything returns to a normal condition, leaving the 
skin somewhat pigmented. 



CONSTITUTIONAL SYPHILIS 99 

In some cases, however, the skin is pierced and through the 
opening which is formed are felt pieces of necrotic bones. The 
necrotized phalanx is gradually destroyed by suppuration and cast off. 
The swelling diminishes and healing takes place, but the finger remains 
shortened on account of the loss of bone. When the joint is involved 
in the process, an anchylosis may result on account of adhesions and 
contractions of the fibrous tissues. 

These affections of the phalanges are only a very late manifesta* 
tion in acquired syphilis, but in cases of hereditary lues they show up 
early, in the first year of life. They are not limited to the phalanges, 
but the bones of the metacarpus and metatarsus are also affected. The 
process is slow and tardy as we have noticed in all syphilitic affections 
of the bones. 

In establishing the diagnosis of syphilis of the bones, we must not 
forget that other affections may produce disease of the bony tissue. In 
workingmen employed in match factories, where they are exposed to 
phosphorous vapors, a necrosis of the jaw may occur and is known as 
phosphorous necrosis. The seat of the necrosis and the occupation of 
the patient will place us in a position to eliminate syphilis. 

In consequence of gangrenous mercurial stomatitis the bone may 
become denuded and suffer necrosis. It has, however, different char- 
acteristics from the syphilitic affections, where formative osteitis is 
the predominating feature. 

In syphilis several bones are affected at the same time, and this 
will exclude a traumatic affection. 

Tuberculosis affects the bones, usually leading to caries. The 
bones which are affected by syphilis are usually spared by tuberculosis. 
We have seen that the frontal and temporal bones are frequently 
affected by syphilis, but very rarely by tuberculosis. Vice versa, the 
temporal bone, which is only rarely attacked by syphilis, is often the 
seat of caries from tuberculosis. Syphilis prefers to attack the 
diaphyses and the long bones, while scrofula oftener affects the short 
bones of the spongious kind. 

The presence of the tubercle bacilli in the purulent exudation 
will be the absolute proof of the tubercular origin of the affection of 
the bones. But it must not be forgotten that scrofula may be asso- 
ciated with syphilis in the same individual. 

The syphilitic affections of the bones are, as a rule, found in an 
advanced stage of the evolution of syphilis, and therefore belong to 
late symptoms ; consequently the individual has already had other 
syphilitic troubles on the skin or on the mucous membranes, of which 
there must remain some traces. By an accurate examination of the 
body we will find signs of an old syphilis and this will give us a clue 
for a differential diagnosis. 



100 THE MEDICAL ASPECTS 

There may be also taken into consideration the character " a 
javantibus " and " lcedentibus/ J which is to give antisyphilitic treat- 
ment and from the obtained results trace the syphilitic origin of the 
disease. This, however, must be considered as a poor and deceitful 
argument for a diagnosis. 

In many cases of rheumatism, we find syphilis to be the cause. 
Like any other infectious disease, syphilis affects the joints with such 
persistency that it has been one of the symptoms which mostly at- 
tracted the attention of the observers. Babington, Ricord and Richet 
have looked upon some forms of artropathies rather as complications 
of syphilis ; but Lancereaux firmly established the existence of arthritis 
from a syphilitic origin, by finding gummous infiltration in a knee 
joint. Oedmansson pointed out a form of synovitis with erosions of 
the cartilages of the joints, as of syphilitic origin. This was after a 
while confirmed by Schuller, Falkson, Finger, and others in a series 
of well-studied cases. 

No joint escapes the attacks of syphilis, but the most frequently 
affected are the knees and the elbows. 

The first symptoms which begin to trouble the patient at the time 
of the syphilitic invasion are pains in the joints. These pains usually 
make their appearance a few days before the roseolar eruption, or they 
may come at the same time, or a short time after the roseolar eruption. 
Several joints are affected at the same time, and at this period the 
trouble is of an irritative character, because there are usually no 
objective symptoms present. The pains are similar to those in rheu- 
matism ; they increase at night and are often accompanied by syphilitic 
fever. They often recur, as we have had occasion to observe in some 
cases where every eruption was accompanied by articular pains. 

Monoarthritis with a marked swelling of the joint we have always 
looked upon as a symptom of late syphilis, or otherwise of hereditary 
syphilis. The cases which have come under our observation were at 
least one year or two after the infection. Syphilitic arthritis begins 
with pains, accompanying an attempt to move the joint to its full ex- 
tension or flexion, and the joint is found to be somewhat swollen and 
the skin is red. By palpation some points can be found in the joint 
where the pain is more accentuated. In some cases fever accompanies 
the affection, and is remittent in type. In the ordinary cases the 
synovitis undergoes involution, and after two or three weeks the joint 
gradually returns to a normal condition. 

In some cases synovitis may take a chronic course ; there is a very 
mild pain, but the swelling is greater, due to a large effusion of serum 
in the joint, which is called hydrarthrosis. Under proper treatment 
the serum is reabsorbed, the swelling diminishes and the condition is 









CONSTITUTIONAL SYPHILIS IOI 

improved ; but in some cases relapses are seen quite frequently, while 
in other cases permanent recovery may be obtained. In cases of old 
syphilis the monoarthritis is somewhat more serious, for the reason 
that a thickening of the capsule may take place, with some impairment 
of the functions. It is a villous hyperplasia of the synovial membrane 
which is at times accompanied by condritis and leaves defects in the 
cartilage. This condition only causes slight pains, but from the 
damaged joint, anchylosis may be the result. In some cases the swell- 
ing of the joint may appear in limited, circumscribed points of the 
capsule or of the ligaments as a gummatous infiltration of the joint. 
The pain is not so severe and the effusion in the joint not so abundant. 
The gumma may be reabsorbed or break down and cause an abscess 
in the joint with external perforation. 

In cases where the joint is attacked secondarily as a consequence 
of osteitis or periostitis the affection is much more severe, and the 
pathological alterations produced on the capsule and on the cartilages 
are usually of such a nature as to cause great damage to the joint. 

We may find some difficulty in establishing the diagnosis of 
syphilitic affections of the joints, in view of possible ordinary or 
gonorrheal rheumatism. In the case of acute polyarthritis the roseolar 
or the papular eruption will soon reveal the syphilitic nature of the 
rheumatism. When it appears later after the infection, the presence 
of periostitis of the tibiae will easily reveal the nature of the arthritis. 

Some difficulty may be found in determining in a case of mono- 
arthritis, whether syphilis or gonorrhea is the cause of the affection 
when both causes have been present. We think, however, that gonor- 
rheal arthritis will soon be found out when we prove the presence 
of an acute or subacute gonorrheal urethritis. The inflammatory 
symptoms of the joint in gonorrheal arthritis are much more violent 
and the pain and swelling are of a much more acute character than in 
a syphilitic arthritis. 

In cases of doubt, we must take under consideration the result of 
the remedies. Salicylic acid will promptly benefit a case of ordinary 
rheumatism, and also a case of gonorrheal rheumatism, but potassium 
iodide will be the best remedy for syphilitic affections of the joints. 

SYPHILIS OF THE MUSCLES AND BURSJE 

The muscles are affected by syphilis in the secondary period, in 
the form of an irritative myositis, and at a late period as a chronic 
interstitial inflammation. 

The vague pains, which are complained of by the syphilitic patients 
at the time of the constitutional invasion, which they usually refer to 
by saying that they are all broken up, may be due to an irritative 



102 THE MEDICAL ASPECTS 

myositis. Indeed, the dolorcs rhcumatodes are quite often referred to 
the joints or to the bones, and yet when we try to locate the pain it is 
found that the muscles are tender, and the bones and joints under 
pressure do not cause any distinct pain. The tenderness is sometimes 
found in the body of the muscle, at other times is limited to the tendon. 
The muscles are found firm, thickened and contracted, and when one 
tries to overcome the contraction, pain is produced. 

Gummatous infiltration also affects the muscles. It presents itself 
in the form of hard and firm knots which follow the movements of the 
muscle, and when pressed produce localized pain. The gumma is 
usually located near the tendons and grows very slowly, gradually be- 
coming softer, while the muscle remains rigid and also contracted. 
In favorable conditions absorption takes place, the muscular fibers 
which have been compressed and destroyed by the gumma are replaced 
by connective tissue. In some cases the gummatous infiltration may 
progress and affects the covering fasciae, proceeding to the subcutan- 
eous tissue and assuming the proportions of a large tumor. It bulges 
out and is very little movable. The skin gradually becomes adherent 
to the whole mass, and is of a bluish red color. The gummatous in- 
filtration, while undergoing disintegration, softens towards the sur- 
face, and forms a large, deep gummatous ulcer. A large quantity of 
the necrotic mass which belongs to the tendons and fasciae is sloughed 
off. It requires many weeks and months before the healing process 
takes place. After the ulcer has healed there remains an iregular deep 
scar, involving tendon and muscle, which remain adherent to the skin, 
with the resulting distortion or permanent contraction. In some cases 
when the gummatous infiltration from the muscle has spread to the 
periosteum or to the bone, a cicatrix may result which adheres to these 
parts and causes great impairment of movement. 

The muscles are also affected by an interstitial infiltration, which, 
starting from the affected blood vessels, causes a compression of the 
muscular fibers. The blood vessels affected in their tunics cannot 
nourish the muscular fibers, and in consequence they undergo degenera- 
tion, and the muscle is converted into a fibrous tissue. The nuclei of 
the sarcolemma which stand together in groups, on account of the 
pressure of the infiltrating cells and of the proliferation of the con- 
nective tissue elements, are cut off from their nutrition, and the con- 
tractile substance is atrophied and a thick connective tissue takes its 
place. This form of myositis begins with pain and swelling of the 
muscle, as an ordinary muscular rheumatism, and by the degeneration 
of the muscular fibers in connective tissues, leads to permanent contrac- 
tion of the muscles. In some cases of torticollis syphilis is the cause 
of the contraction of the sterno-cleido mastoid muscle. 



CONSTITUTIONAL SYPHILIS 



103 









Affections of the muscles are always found in grave cases of 
syphilis, and at a late period ; the diagnosis will therefore be helped 
by the presence of periostitis, of scars of healed up gummata. Usually 
several muscles are affected at the same time. In cases of a single 
gumma of the muscles some doubt may arise in the differential 
diagnosis between gumma and sarcoma or other new growths. In 
these cases we believe a great deal in the argument of a juvantibus, 
and a few weeks of a well-directed specific treatment will solve the 
problem. 

The tendons have been reported affected in syphilis in the form of 
tendo-synovitis, by Herman Holder, 1851, revealed by swelling of the 
sheaths of the tendons. Yerneuil found, at an early stage of syphilis, 
acute painful hygroma in the sheaths of the tendons of the fingers. 
Alfred Fournier considers the occurrence rather common and refers 
to cases of hygromata in the extensor of the toes, the tendo-Achillis, 
biceps brachii, biceps femoris, supinator longus, and peronei. Observa- 
tions of the kind have also been reported by Baumler and Chouet. 

The tendons are affected in the form of an acute, irritative tendo- 
synovitis, which is an inflammatory process of the sheath of the tendon, 
accompanied by pain and some exudation. Motion is painful, and a 
kind of crepitation is produced on account of the exudation in the 
sheath. It may end in resolution or in hydrops of the sheath. 

The tendo-synovitis may be chronic, and is either the result of the 
acute form, or begins as such, with little pain and a great quantity of 
exudation. It remains stationary for a long time, causing hyperplasia 
of the tendon sheath and hygroma. 

Gummatous tendo-synovitis shows a round spindle-shaped swelling 
around the affected tendon. It grows slowly ; little or no pain is 
present. It remains for some time as a gummatous swelling, and 
finally is either rebasorbed or, undergoing degeneration, breaks down, 
affecting the surrounding tissues and ulcerating the skin. 

Swelling of the bursas is quite frequently found in syphilitic 
patients. We often have occasion to see bursitis of the bursa prepatel- 
laris, which attains large proportions in the form of a defined fluctuating 
tumor in front of the rotula. Lang refers to cases of bursitis of the 
olecranon at an early period of syphilis, which have resolved and dis- 
appeared under antisyphilitic treatment. Fournier also reported cases 
of hygroma prepatellaris, and Verneuil found a fluctuating tumor of 
the bursa olecrani in a man affected with syphilitic roseola. 

Cases of gummatous infiltration of the bursse have been reported 
by Lang and by E. L. Keyes, which ended in sinuses and fistula?. 

In our experience we have met quite frequently with hygroma of 
the bursa olecrani, and of the bursa prepatellaris. In all cases syphilis 



104 THE MEDICAL ASPECTS 

had been inoculated several years before, and antisyphilitic treat- 
ment produced the complete reabsorption of the fluid forming the 
hygroma. 

Syphilis also affects the aponeuroses and the ligaments ; in ordinary 
cases in the form of diffused infiltration, which is revealed as small 
nodules scattered on the surface of the fasciae, with some tenderness. 
This specific inflammatory form has been found at different stages of 
the evolution of syphilis. 

Gummata of the fasciae have also been described, but on account 
of their thin structure will soon affect the neighboring tissues, and it 
would be difficult to establish the place of origin of the gumma. 



VI 

SYPHILIS OF THE NERVOUS SYSTEM 

That the nervous system is exposed to the ravages of syphilis was 
supposed when syphilis first began to be studied with some attention. 
The first idea, however, was that expressed by Botal and Fallopius, 
that the symptoms of the nervous system were the consequence of the 
syphilitic affection of the bones in the form of necrosis, tophi or gum- 
mata, which damaged the nervous substance. A gummatous process 
affecting the brain had, however, been already recognized. Progress 
on the subject was stopped by the misleading statement of Hunter 
claiming that he had never observed syphilitic affections of the internal 
organs or of the brain. The every day observation, which clearly 
showed cases of peculiar affections of the nervous system in individuals 
who had suffered severely from syphilis, revived the old ideas expressed 
by Fallopius and Botal, that syphilitic deposits in the bones were 
accountable for the grave symptoms of the brain. 

THE BRAIN" 

The careful study of the nervous affections, which was begun in 
earnest towards the middle of the last century, revealed that cerebral 
symptoms are the direct result of syphilitic attacks on the nervous cells, 
and that only rarely are they due to the presence of exostoses. 

We have already spoken of some neurotic condition affecting deli- 
cate patients in the form of headache, vertigo, irritability, on the first 
invasion of constitutional syphilis. It seems that this condition may be 
ascribed to a certain degree of hyperemia or even of slight effusion into 
the meninges or the brain. This irritative condition of the meninges 
may represent in some way the irritative eruption affecting the skin 
at the time of the appearance of the secondary symptoms. This was the 
opinion of Prof. Sigmund, who referred to an irritative disturbance 
of the meninges, the loss of sleep, the peculiar lassitude, and the 
irritability shown by some patients at the time of the invasion of the 
secondary symptoms. 

Alrik Ljunggren maintains as an established fact during the first 
stage the occurrence of a temporary hyperemia of the cerebral meninges 
or of the interstitial matter, which he compares to the hyperemic forms 
of the secondary syphilitic eruptions. He insists that cases of menin- 

105 



106 THE MEDICAL ASPECTS 

geal irritation at the period of invasion of syphilis have not to be 
counted a rare affection. 

In meningeal irritation the headache is sometimes marked on the 
frontal region, some other times on the occiput, while in some cases 
the whole cranium is affected. It makes its appearance as a neuralgia, 
which is sometimes accompanied by vertigo and by mental irritabilty. 
In some cases there has been found some irregularity in the size of the 
pupils, probably from paralysis of the sphincters, and others have 
called attention to a slow pulse. The affection has been considered as 
one of short duration, which easily yields to the mercurial treatment. 
We have seen this affection in a patient affected with papular syphilide, 
who from the intensity of the pain could not sleep during the whole 
night, in spite of opiates and hypnotics administered. The syphilitic 
cephalalgia finally yielded to a protracted mixed treatment, but was 
rather stubborn. 

Lang is also of the opinion that this affection is the result of a 
meningeal irritation with a probable infiltration, on account of the exist- 
ence of similar irritative changes, which in many cases can be 
demonstrated in the fundus of the eye. He had examined ophthalmo- 
scopically a large number of patients in the early stage of syphilis. 
Of forty patients, only nineteen showed the normal color of the fundus 
of the eye ; of the twenty-one, in fourteen there was found choroidal 
irritation in different degrees, and in seven Lang was able to dem- 
onstrate an inflammatory process of the choroid or of the retina. 
These changes in the fundus of the eye, which he found repeatedly in 
the early stage of the constitutional syphilitic affections, have fre- 
quently attained such a high degree as was found in retinitis with as 
grave consequence on the visual function, and yet the vision was not at 
all or only slightly impaired. 

Syphilitic meningitis is quite difficult to demonstrate during life. 
It has also been found in the form of gummatous meningitis, ending in 
connective tissue callosities. A circumscribed spot of constant pain in 
the head, sometimes increased by percussion, may be a good character- 
istic for a pachymeningitis affection, but will not exclude the possibility 
of the presence of a gummatous osteitis of the bones of the skull. 

Gummatous products have been found in the membranes of the 
brain. In the dura mater the gummatous infiltration is developed be- 
tween its layers, assuming sometimes the size of a walnut, and made up 
of fibrillary tissue containing a large quantity of cells, with some signs 
of fatty degeneration. A gumma of the dura mater always causes a 
certain pressure on the lamina vitrea of the bone of the skull, producing 
a kind of erosion. This does not occur in the case of a gumma of the 
pia mater, which leads to adhesions between the pia and the dura, and 






§YPHILIS OF THE NERVOUS SYSTEM 107 

between the pia and the cortex of the brain. It appears like a deposit 
of reddish, jelly-like pulp, which infiltrates the meninges in circum- 
scribed points. In some cases of gummata of the pia the infiltration 
does not remain limited to the membranes, but affects the cortex and 
also the white substance, with disastrous consequences to the life of the 
surrounding brain substance. 

One of the most frequent forms of syphilitic affections of the 
meninges is that of a diffused meningitis gummosa basilaris. It is 
often found in the neighborhood of the chiasm involving the oculo- 
motor, the optic and other cerebral nerves. In the autopsy x of a girl 
eighteen years of age, who had been affected with progressive idio- 
pathic atrophy of the skin, there was found a gummatous infiltration 
in the form of a gelatinous mass on the upper part of the right optic 
tract, which pressed on the right middle cerebral artery, and another 
mass of infiltration was found on the right surface at the junction of 
the pons and medulla. To the first was to be attributed the impairment 
of the vision, and to the latter the atrophic degeneration of the skin. 

It seems that the gumma of the brain has its origin in the pia, and 
from that affects the cortex and also the white substance of the brain. 
Only a few gummata have been found in the substance of the brain, 
which is the consequence of the obliterating process of one of the 
arteries, and the result is the softening of the brain around the gumma. 

Syphilis, when it affects the brain or its membranes, producing 
alterations of organs of the greatest delicacy and of vital interest, must 
produce changes in the most important functions of life ; in the mental, 
in the sensory, in the motor, also in the trophic sphere. It will be re- 
vealed in the beginning by an increased irritability of the patient, or a 
lowering of the intelligence, a diminished power of attention, and later 
on by psychoses of different kinds. 

Headache is a constant symptom, which precedes and accompanies 
syphilitic affections of the brain. At times it attacks the whole head : 
at times the pain is limited to one part of the head. Headache from 
a syphilitic affection of the meninges or of the brain is likely to increase 
at certain hours of the day, becoming excruciating at night, and rarely 
presents a total intermission. When the headache is constantly limited 
to one point for a long time it can be considered as a symptom of a 
localized process. Vomiting sometimes accompanies the headache. 

At the same time that patients are suffering with the headache 
they are troubled with insomnia, with the flashing of lights before their 
eyes, are extremely irritable, and they sometimes suffer with vertigo. 
The patient gradually loses his memory and is not able to concentrate 

1 Ravogli, A. " A Case of Progressive Idiopathic Atrophy of the Skin." 
The Journal A. M. A., Jan. 10, 1903. 



108 THE MEDICAL ASPECTS 

his thoughts. In some cases the patients are affected with epileptic 
convulsions. In our practice a young man affected with cerebral 
syphilis could not walk straight without leaning against the walls of 
the houses, and when without support he always fell on his left side. 
The pulse is usually retarded, but in some cases accelerated or even 
irregular. In syphilis of the brain there has also been observed poly- 
uria and polydipsia as frequent accompanying symptoms. 

Optic neuritis is often found in syphilitic affections of the brain 
with little or with great disturbances of the visual power. In syphilitic 
ependymitis a constant violent headache with exacerbations is one of 
the symptoms. This is so intense that when the patient tries to raise 
his head he is taken with nausea and vomiting. The psychical func- 
tions are somewhat weakened. The pupils are usually dilated, the 
visual power diminished, and the fundus of the eye is passively 
congested. 

When parts of the brain are involved in the syphilitic process 
symptoms arise which lead us to the diagnosis and to the determina- 
tion of the affected locality. Recent physiological and pathological 
researches have shown positively the functions of the different tracts 
of the brain, so that from the disturbed function we can establish to a 
certainty the tract of the brain affected by the infiltration or by the 
effusion. It is clear that the motor tracts which take their origin from 
the central convolutions pass through the corona radiata, the internal 
capsule, reaching the cerebral peduncles, the pons to the crossing of the 
pyramids, if an effusion, a hemorrhage, or a gumma is found in one of 
these spaces where the fibers run together, complete hemiplegia will be 
the result. On the contrary, if this alteration takes place on the cortex 
it will cause only a circumscribed paralysis, a monoplegia. These 
isolated forms of paralysis are frequently met with in the leg, arm and 
face. Monoplegia facialis is quite often associated with monoplegia 
of the arms, while paralysis of the arm and leg together is less common. 

A cortical lesion can be assumed with some degree of certainty, 
when partial jactitations are confined to single muscular areas at the 
beginning of a cerebral hemorrhage or when a tumor is developing. 
According to Nothnagel the diagnosis can be made with certainty 
when clonic contractions appear at a later period in the paralyzed parts. 
The convulsions may affect circumscribed regions, or several regions 
together, as arms and face; or they can attack one-half of the body 
in the form of cortical epilepsy, which is known as Jacksonian epilepsy. 

The motor cortical area is situated in the anterior and posterior 
central convolutions, and in the medianly situated lobulus paracen- 
tralis ; motor areas are found also in the contiguous portion of the 
superior parietal lobe, and probably also in the gyrus frontalis superior. 



SYPHILIS OF THE NERVOUS SYSTEM 



109 



In general, we find that the upper portion of the central convolu- 
tions, preferentially the lobulus paracentralis, are the center for the 
movements of the leg. The middle portions, anterior of the central 
convolutions, preside over the movements of the arms, while those 
below control the movements of the face and tongue. The tactile 
cortical area is entirely associated with the motor areas, so much so that 
Wernicke and Munk call the motor region the tactile region. This, 
however, is found not exactly corresponding to the clinical observa- 
tions, and Nothnagel has found that the surface of the brain lesions 
causing motor paralysis is not exactly the same that produces disturb- 
ance of muscular sensation, although both are situated so near to each 
other. Cases of syphilitic affection of the cortex have been reported 
where marked monoplegia was present ; but the sensation of the skin 
was maintained. In other cases where monoplegia and spasms were 
present the sense of touch was entirely abolished. 

Clinical observations show that these nervous centers are quite 
often affected by syphilis, and cortical epilepsy, without a traumatic 
cause, is more frequently the result of syphilitic affections. Partial 
epilepsy or the hemiplegic form is usually preceded by an increase of 
headache, which is of a unilateral character, or radiates from a single 
point of the face and throat. Convulsions in the form of rhythmic mus- 
cular contractions appear in one extremity and soon affect the other of 
the same side, involving also the muscles of the face and head. The 
mind is somewhat obscured and the patient falls. The attack may last 
one hour or even more, and as a result of the attack there may 
temporarily remain a difficulty of speech, weakness of memory, or of 
the affected limb. The attacks usually recur after weeks or months. 
It is only very rarely that they appear daily, at the same hour. 

The convulsions, according to Charcot, in partial epilepsy caused 
by syphilis, maintain a certain rule in the order of jactitations. When 
the convulsions affect the upper extremity the face will be next 
attacked, and then the lower extremities. If the face is first attacked, 
the convulsive movements will affect the upper extremities first and 
then the lower, finally when convulsions begin in the lower extremity 
they attack first the upper limb and then the corresponding half of the 
face. In partial epilepsy the consciousness is clouded only when the 
convulsions affect the face. 

In cases when consciousness is retained the convulsive form of 
the disease may occasionally simulate chorea. 

These affections have always been found to correspond to altera- 
tions of the cortex caused by exostoses or a gummatous process. H. 
Oppenheim found in a post-mortem a hyperostosis of the left cranial 
vault, and a diffuse gummatous infiltration of the dura, near the 



HO THE MEDICAL ASPECTS 

frontal lobe affecting the central convolutions, and part of the left 
parietal lobe. The man, who was thirty-nine years old when he died, 
had complained during life of a tenderness of the left side of the skull, 
paresis of the right extremities, disturbance of the sense of position in 
the right foot, clonic spasms, paresthesias, which extended from the 
right foot to the right half of the body, and after a while he was 
affected with aphasia and hemiparesis of the right side. 

In one case of epileptic attacks from syphilitic affection of the 
brain, referred to by Byron Bromwell, there were found no peculiar 
alterations of the central convolutions. The patient was a man thirty- 
four years of age, who had been infected seven years previously, and 
for some time had epileptic attacks, which occurred without any 
disturbance of consciousness, and hemiplegia of the left side, which 
had improved under a mixed treatment. He died after a convulsion 
which lasted three days. The post-mortem showed adhesions of the 
dura to the brain in the posterior portion of the second right cerebral 
convolution, and the posterior portion of the middle and upper frontal 
convolutions were infiltrated throughout the whole extent by a firm 
gumma, while the central convolutions and the rest of the brain were 
normal. 

Cases of aphasia have been observed in consequence of cerebral 
syphilis. Lang observed a case of motor aphasia in a patient ten years 
after infection. He had suffered severe secondary symptoms, asso- 
ciated with persistent neuralgia. The patient died afterwards with 
severe cerebral disturbances. Other cases of permanent aphasia as 
a result of cerebral syphilis have been referred to by C. Wunderlich, 
and by C. Wernicke. 

Some cases of aphasia were accompanied by alexia, although the 
vision was maintained intact, and agraphia, although the motility was 
not disturbed. In some cases alexia alone has been found, which has 
gradually disappeared under specific treatment. 

The base of the brain is often subject to syphilis, in the form of 
diffused or circumscribed syphilitic infiltration. In this case the cere- 
bral nerves are involved, together with the neighboring portions of the 
brain. The resulting symptoms are partly produced by the affected 
nerves and partly by the involved cerebral areas. In consequence of 
the alterations of the blood vessels, it is not rare to find a basilar 
meningitis, hemorrhages, and softening of the brain substance. 

This affection is sometimes confined to single nerves or to their 
branches, at other times as a larger area of the base is affected, several 
of the cerebral nerves are involved in the process. During the evolu- 
tion of cerebral syphilis we not infrequently meet with cases of optic 
neuritis, choked disc, and atrophy of the optic nerve. But sometimes 



SYPHILIS OF THE NERVOUS SYSTEM m 

the affection extends forwards to the olfactory nerve, or backwards to 
the trochlears, trigeminus, abducens and also to the facial and auditory 
nerves. When the gummatous process remains localized in the pos- 
terior meningeal portion, then the hypoglossus, the vagus, etc., may 
be affected. 

The neighborhood of the chiasm is quite often involved in basilar 
meningitis, and this explains the^ frequent affections of the optic nerves 
and of the ocular muscles. H. Oppenheim considers as a characteristic 
symptom of syphilitic affections of the base, oscillating hemianopsia 
bit emp oralis. The appearance and disappearance of the hemianopsia 
is explained by the great quantity of blood vessels, which according to 
the quantity of blood, produce temporary swelling of the tissues. 

When basilar meningitis attacks the posterior portion, then the 
symptoms will reveal affections of the pedunculi cerebri, the pons, the 
cerebellum, the medulla oblongata, etc. 

In the affections of the cerebral peduncles, symptoms of crossed 
paralyses are obvious, in which the cranial nerve, especially the oculo- 
motor of the side where the syphilitic lesion is, and the extremities of 
the opposite side are involved. This was called by Leyden hemiplegia 
alternans superior. When we find paralysis of the facialis on one side 
and paralysis of the extremities on the other, it is a symptom of hemi- 
plegia alternans inferior of Gubler. Paralysis of the cerebral nerves 
occurs on the same side of the affection of the peduncles, while the 
body is affected on the opposite side, because the motor fibers from the 
cortex going to the spinal cord cross lower down in the pyramids. 

When the pons is affected, the facial nerve is more often impli- 
cated, and there are also present disturbances in the power of speech 
and of deglutition. In the case of involvement of the corpora quadri- 
gemina there is bilateral lesion of the branches of the oculo-motor, 
together with disturbances of the equilibrium and of co-ordination, as 
in the affections of the cerebellum. Indeed, when the cerebellum is 
involved there are some peculiar changes in the gait and disturbed 
equilibrium. In walking, the patient is unsteady, and goes like a 
drunken man. 

Gummatous syphilitic infiltrations have been found in the medulla 
oblongata, which had caused different and peculiar symptoms during 
life. In the case of progressive idiopathic atrophy of the skin in a 
young woman, already referred to, a gummatous infiltration was found 
on the right surface at the junction of the pons and medulla, which is 
considered the center of the vasomotor nerves of the skin. The affec- 
tion of the skin was accompanied by several areas of anesthesia. 

Syphilis may be the cause of affections of the brain substance in 
the interior of the organ. These affections are more frequently found 



112 THE MEDICAL ASPECTS 

in the corona radiata, and in the central ganglia, and also in the sub- 
stance of the cord. In these parts syphilitic gummatous infiltrations 
or limited gummata are very rare, but hemorrhages, and softening 
foci, on account of the altered condition of the blood vessels, are fre- 
quently found. 

In the affections of the corona radiata, and of the internal capsule, 
paralysis is much more extensive and complete, without any signs of 
irritation. Indeed, the fibers from the cortex run through the corona 
radiata and the internal capsule, which is between the large basal 
ganglia. Any effusion or softening foci involving one organ must 
directly or indirectly affect the other. 

The symptoms will depend exactly upon the size and extension 
of the focus. It is not possible to determine whether the affection is 
the result of gummatous infiltration or whether it is the result of the 
affected blood vessels. Symptoms are of a somewhat common order, 
usually revealed by headache, vertigo, insomnia, mental irritability, 
loss of memory, accompanied by a general mental deterioration. 
Hemiplegias and hemipareses are liable to occur suddenly without loss 
of consciousness ; in some cases they are preceded by an apoplectiform 
attack. In some cases paralysis gradually subsides, in others it may 
quickly disappear. Hemianesthesia, aphasia and hemianopsia, due to 
central lesion, are found with the other symptoms. 

In the affections of the blood vessels from lues, the oscillating 
character of the symptoms is one of the best signs, being due to the 
changes of the blood supply. 

In a large number of observations, there only appeared general 
cerebral symptoms, and local symptoms were only added later, and 
sometimes, never appeared. In several of our cases epileptic attacks 
have followed the various general symptoms, which have been relieved 
or discontinued by the antisyphilitic treatment. 

Cerebral syphilis, as we will see in the following chapter, is quite 
frequent in our times. It is possible that the increased mental work, 
the mental strain, and the worriment in the struggle of life have 
multiplied the possibilities for its occurrence. It has a chronic course, 
and although greatly influenced by the antisyphilitic treatment, it im- 
plies a dark prognosis for the future of the patient. 

THE SPINAL CORD 

Although it has been asserted that syphilitic affections of the 
spinal cord are of rare occurrence, yet from the studies of Rumpf, 
Oppenheim, Sachs, Siemerling, and especially from the investigations 
of Erb, we find that the medulla spinalis is not infrequently affected 
during the course of syphilis. 



SYPHILIS OF THE NERVOUS SYSTEM 113 

It is not improbable that some irritative symptoms, which are 
observed at the time of the invasion of syphilis, such as vague pains, 
paresthesia of the legs, a feeling of debility, may have some reason for 
their existence in an irritation, direct or reflex, of the spinal cord. In 
fact, when a roseolar or papular eruption affects the skin and the 
mucous membranes, it is not impossible that the presence of an hyper- 
emia or slight infiltration on the meninges of the cord causes the above 
referred to symptoms. Jarisch and Finger have reported cases of 
increased reflexes of the skin and tendons in recent syphilis, before, or 
at the time of the appearance of the eruption. In some cases the in- 
crease of the reflex was followed by a decrease in the reflex irritability, 
which gradually, after some treatment returned to the normal. 

It is possible that on account of syphilitic periostitis of the verte- 
brae the process may reach the meninges, and so produce a spinal 
meningitis. But this is only a very rare occurrence, as the intervening 
fatty tissues protect the dura. The process more often starts from 
the pia, which leads to the adhesion of all the meninges together, con- 
sequently involving the roots of the spinal nerves. 

Spinal meningitis, like cerebral meningitis, shows as results of its 
alterations, gelatinous masses covering the cord, or dense fibrous 
vegetations made up of connective tissues, and packed with mono- 
nuclear leucocytes. Gummatous foci are also scattered through the 
mass. 

Spinal meningitis is more frequently found in a diffuse form than 
in a circumscribed one, and the dorsal section is more often affected. 
The cord is not equally affected by the infiltration, but some regions 
are more thickened than others, and the posterior sulci are more 
intensely affected. 

The lesions from the pia extend to the external surface of the 
cord, and from there affect the interior parts. The blood vessels 
affected with the luetic affections either fail to nourish the nervous 
cells and cause softening, or break and produce hemorrhages. 

Isolated gumma in the spinal cord have only rarely been found. 
It is more usual to find diffuse gummatous infiltrations, which form 
between the meninges and the cord jelly-like or dry, cheesy masses, 
which are found scattered over a large surface. 

The nerve roots when involved by the infiltrating process cause 
interruption of the conducting tracts with disturbances either of the 
motor and of the sensory sphere or of the trophic functions. 

The symptoms of syphilis of the spinal cord vary a great deal 
according to the tracts and to the extension of the affection. As 
general disturbances, it causes a certain degree of stiffness of the 
spinal column, and a sense of heavy weight of the extremities ; to this 



114 THE MEDICAL ASPECTS 

are to be added various neuralgic pains around the chest, and pares- 
thesia. When the process has attacked the conducting tracts then 
pareses of the sense or of the motor sphere begin to appear. 

In case the gray substance of the anterior horns of the spinal cord 
is involved the muscles depending on the affected tracts will suffer, 
either falling into paralysis and then into an atrophic condition, or 
remaining in a spastic form. Paresis of the bladder and of the rectum 
follows, and the tendon reflex is usually greatly lowered. These 
symptoms take some time before they show up in their full develop- 
ment, and after a well-directed treatment, they may gradually dis- 
appear, or they may inexorably continue in their progress. Then, 
according to the tracts of the spinal column affected, we see hemi- 
paresis, or paraparesis in correspondence with the cross sections. 

It is clear that when the dorsal or lumbar region of the cord is 
affected by a gummatous infiltration the abdominal and intercostal 
muscles will suffer, and paraplegia of the lower extremities will follow 
with paralysis of the sphincters. The skin, on account of the diminished 
vitality in the place where the patient lies, is readily excoriated, falls 
into necrosis, and decubitus follows as a complication. In the same 
way the patients suffer with cystitis in consequence of the paralysis. 

When the cervical portion of the spinal cord is the seat of the 
syphilitic alterations, then stiffness and paresthesia of the neck and 
arms will be the first symptom. In consequence of paralysis of the 
diaphragm the patient may undergo attacks of dyspnea or asphyxia. 
The affection may show only a unilateral or bilateral tendency, 
it may spread gradually from the upper to the lower extremities, or, 
vice versa, from the lower extremities the paralysis may ascend to the 
upper regions of the body. 

As we have seen that paralysis of the lower limbs leads to severe 
and dangerous complications of decubitus and cystitis, so paralysis of 
the respiratory muscles may cause inflammation and gangrene of the 
lungs, and on account of the paralysis of the phrenic nerve, the 
diaphragm is impaired in its function, and asphyxia ends the life of 
the patient. 

The spinal affections from syphilis appear gradually, and some- 
times they accompany the same affection of the brain, showing a 
descending course, in the form of cerebro-spinal syphilis, as noted by 
Jurgens, Oppenheim, and Sachs. 

In spinal syphilis we always have hopes that the symptoms will 
recede, and especially after a well-directed antisyphilitic treatment, the 
condition improves, the muscles regain their power ; but some irrepar- 
able changes in the delicate structure of the nervous system remain 
with permanent results. 



SYPHILIS OF THE NERVOUS SYSTEM 



115 



In the cases where the posterior roots of the spinal cord are 
affected the symptoms have a great resemblance to those caused by 
tabes, so much so that Oppenheim called it pseudo-tabes syphilitica. 
In fact, we find that the patellar reflex is absent, the patient complains 
of lancinating pains, shows an ataxic gait, immobility of the pupils, 
inability to retain or void urine : all symptoms which we find in tabes. 

Erb has claimed to have found a special type of symptoms coming 
from a diseased spinal cord, which he considers invariably due to 
syphilis. The symptoms are spastic paraplegia, with a peculiar gait, 
exaggerated reflexes, muscular contractions slight in comparison with 
the increased reflexes, involvement of the bladder, disturbance of sen- 
sation, gradual onset of the disease, finally a tendency to improvement. 

This type of spinal syphilis, however, does not include all severe 
cases of this disease. It comprehends cases of syphilitic spinal men- 
ingitis, with some infiltration of the lateral columns, but not those with 
deep gummatous infiltration or true syphilitic myelitis, where improve- 
ment, if at all, is only temporary, and ends with irreparable paralysis. 

In cases of gummata of the spinal cord, the affection, although 
very rare, is usually limited to the anterior horns. The muscles, par- 
tially paralyzed, show an inclination to atrophy; they do not react to 
the irritation of the faradic current, but show some irritability with the 
galvanic current. The affected locality will be easily determined when 
together with the above mentioned symptoms we find no disturbances 
of the bladder and of the rectum, or troubles of the sensory sphere. 

Many nervous affections have been referred in some instances to 
syphilis, such as progressive muscular atrophy, especially that of the 
type known as Aran-Duchenne, where the paralysis and the atrophy 
are principally marked in the hand, in the thenar and hypothenar 
eminences, the interossei and the abductor indicis. The Erb spastic 
paralysis has also been referred to a syphilitic infection by Leyden, 
Minkowski and Naunyn. This is characterized by a spastic paralytic 
condition of the muscles, without any disturbance of the bladder, rec- 
tum, or of the sensory sphere. 

From a gummatous meningitis a multiple syphilitic root neuritis 
may result. It is the production of a small cell infiltration on the 
epineurium of the pia, which pressing on the roots of the nerves, 
causes atrophic condition of the nerve fibers. 

When in a case of syphilis of the brain, already manifested by 
paralysis of the cranial nerves, such as the facial, or those of the 
ocular muscles, a gradually progressive paralysis of the spinal nerves 
takes place, we can, in such a case, assume the existence of a syphilitic 
neuritis of the roots. The affection is then usually accompanied by 
various neuralgias of the spinal nerves, with hyperesthesias of the skin. 



Il6 THE MEDICAL ASPECTS 

girdle pains, and if it affects the anterior roots, spasms and motor 
palsies will be present. In these cases the administration of anti- 
syphilitic remedies has failed to bring any benefit, and for this reason 
have been regarded with some doubt as true syphilitic affections. 
Fournier has comprehended all those affections, which are rather con- 
sequent to degenerative processes of syphilis than the direct result of 
the disease, in one group, which he has called parasyphilitic affections 
of the nervous system, which we shall consider in the next chapter. 

GENERAL SYPHILITIC AFFECTIONS OF THE NERVOUS SYSTEM 

There is no doubt that syphilis, of late years, on account of a more 
judicious treatment and of the facilities for its application, has lost 
some of its virulence and malignancy. Indeed, we but rarely find at 
present cases of malignant syphilis, which we have seen in the preced- 
ing chapter, to be mostly due to the lack of resistance of the infected 
organism. But although its manifestations are milder and easily yield 
to treatment, yet its pathological domain has greatly enlarged by the 
knowledge of the complexity and character of its morbid processes. 

Formerly the study of the cutaneous manifestations of syphilis 
formed the most important subject of its symptomatology; but to-day 
the visceral affections, cerebral, spinal, vascular, ocular, articular, pul- 
monary, hepatic and renal attacks are of the greatest significance. As 
a consequence, the infection of syphilis to-day, although mild, and 
better treated, has a much more profound and permanent character 
than we have at first believed, when we think that it affects every con- 
stituent element of the body, and may produce systemic complications 
of a serious nature, which often have a fatal termination. 

The idea that syphilis has assumed a milder appearance, that its 
manifestations are much less severe, that its apparent cure is much 
more easily effected, that cases of death from syphilis are extremely 
rare, is all very true, but we cannot deny, as Morrow 2 very wisely main- 
tains, that a great number of deaths from apoplexy, paralysis, consump- 
tion, hepatitis, Bright's disease, etc., etc., recognize as their remote 
factor this protean morbid affection, syphilis. 

Mucous membranes and the skin are the organs preferred by 
syphilis in its manifestations, the brain and the spinal cord coming 
next in frequency. In fact, Fournier, from his personal statistics, 
gathered in a period of thirty-nine years and embracing 4000 cases of 
tertiary syphilis, shows that next to the skin, the brain and the cord are 
the organs most frequently affected. Cutaneous tertiary manifestations 

2 Morrow. " The Prophylaxis of Venereal Diseases." Philadelphia Medical 
Journal, 1901. 



SYPHILIS OF THE NERVOUS SYSTEM 117 

number 1145, affections of the brain 758, and those of the spinal cord 
1098, giving a total of 1856 cases in which the brain and the spinal 
cord had been affected. 

It is worth while to follow these statistics, and we find that 354 
of these cases of cerebral syphilis have reached a known termination ; 
yy were cured, 68 died, while 209 survived, but with various infirmities 
of a grave character irremediable in every case. 

In our experience we have had several important cases of syphilitic 
patients, which have ended with cerebral and spinal complications. It 
is quite easy to find a case of syphilis of- the nervous system, but the 
interesting case is the one in which the disease can be followed from the 
beginning to the end. It is for this reason that we refer to the fol- 
lowing cases : 

In 1883 we were consulted by a young man of German extraction, 
strong and healthy, a butcher by trade, who had recently contracted 
syphilis, and who showed a papular eruption which spread all over his 
body. He was married and had several children, all born before he 
became infected. His wife had already been infected. He and his wife 
were treated with intramuscular injections of a one per cent, solution 
of corrosive sublimate. After sixteen injections he considered himself 
cured and refused any further treatment. His wife came after a few 
years to consult about sores on her legs, which were ulcerated gummata. 
She subjected herself to the mixed teatment of inunctions and iodide 
of potassium, and has never again had any syphilitic manifestation. Her 
husband never had any more symptoms of any kind. He was addicted 
to the use of alcoholics, and had changed his occupation, opening a 
restaurant and saloon. In 1898 we were called to see him. He had 
acute mania, he was threatening everybody in the house, and it was 
necessary to have him taken to the sanitarium, where he died without 
regaining consciousness. 

An Italian fruit dealer, with syphilis in a florid stage, consulted us 
in 1884. He took some treatment, and seeing that he was getting well, 
stopped it and without asking for consent, married a young woman. 
Several years afterwards we were called into his family for the reason 
that his wife had had four miscarriages. He was reminded of the dis- 
ease which he had contracted and the insufficient treatment he had 
undergone. He and his wife were subjected to a mixed treatment of 
mercurial ointment inunctions and large doses of iodide of potassium. 
Since that time his wife has borne five children, who are all enjoying 
good health. They are not the highest type of strength, but with the 
exception of the diseases of infancy, they have never shown syphilitic 
symptoms. The man, however, in 1899, was affected with ptosis of the 
right eyelid, for which he again began treatment. In 1900 he was 



Il8 THE MEDICAL ASPECTS 

affected with a stroke of paralysis affecting the right facial nerve and 
the arm and leg of the left side. He is now taking large doses of 
potassium iodide, his face has nearly returned to the normal condition, 
his left leg is slightly weak, but he can walk with the aid of a cane. 
The arm and the hand are still powerless. 

So much syphilis has been found as the cause of nervous diseases 
thai: Berkeley 3 has attributed to this disease all cases of hemiplegia or 
monoplegia and mental disturbance in people under forty years of age, 
where no cardiac or renal affections could be found. In the same way 
he considers syphilis responsible for all cases of dementia with obscure 
symptoms in patients between twenty-five and forty years of age. 
Moebius 4 considers paresis as a syphilitic toxin disease, and only 
patients who have previously had syphilis are affected by general pa- 
ralysis. According to Fournier, hereditary syphilis plays an important 
part in the development of psychoses, especially in adolescence, and 
Hurd 5 has thought that syphilis may cause any simple psychosis, paresis 
and pseudoparesis. J. H. McBride 6 claimed that syphilitic insanity 
may mimic every known form of mental derangement. He has also tried 
to give a differential diagnosis between mental derangements when 
caused by syphilis, and when the result of other causes. In mania and 
in melancholia, an earlier appearance of confusion and weakness, stupor 
and dementia will point towards a syphilitic origin. It is agreed to by 
the generality of the neurologists that the anterior portions of the brain, 
frontal and central, are more open to syphilitic infection, which ex- 
plains, according to R. Dewey, 7 the frequent dullness and stupor found 
in nervous affections of syphilitic production. 

A certain relation has been found between senility and syphilitic 
insanity, without giving any particular diagnostic points. Spitzka, 8 
calculating on the figures of Snell, claimed that 75 per cent, of cases of 
paretic dementia were due to syphilis. According to the figures of 
Erb, a similar proportion existed for tabes. He, in his practice among 
the insane paupers of New York, found that thirty-three per cent, of 
the cases of insanity was referred to a syphilitic history. But an 
energetic antisyphilitic treatment did not give any result, and in several 
cases intervals of spontaneous improvement occurred independently 
of treatment. 

Syphilis produces alterations in the nerve fibers at the very begin- 

3 H. J. Berkeley. "Mental Disease." 

4 Quoted by Bannister. " General Paralysis a Toxin Disease." Am. Journ. 
Insanity, vol. i. 

5 " Psychosis in Cerebral Syphilis." Journ. A. M. A. October, 1901. 

6 " Paresis and Cerebral Syphilis." Buffalo Med. Journal, 1901. 

7 " Mental Symptoms of Cerebral Syphilis." Journal A. M. A. Feb. 2d, 1901. 

8 Spitzka. " Manual of Insanity." 






SYPHILIS OF THE NERVOUS SYSTEM 119 

ning in the localized initial lesion. Berkley 9 found interstitial and 
parenchymatous neuritis, due to the compression of the infiltrating 
cells, and to the endarteritis interfering with nutrition as a result of the 
local action of the syphilitic virus. The alterations, however, were 
limited to the nerve fibers imbedded in the exudation. In the course 
of syphilis it is not uncommon to meet with cases of root neuritis, cranial 
and spinal, and also peripheral mono-neuritis as secondary lesions. A 
case of syphilitic multiple neuritis was reported by Fry 10 as occurring 
one year after the initial lesion, and others by Cestan. 11 ' It is, however, 
not frequent that one sees neurotic affections as a consequence of 
syphilis in the secondary stage, while in late syphilis the occurrence is 
much more frequent. In the first, especially in women, syphilitic in- 
vasion at the time of the feverish reaction and on the first appearance 
of the erythematous eruption, may be the cause of hemicrania, of hys- 
terical convulsions, and even of temporary delirium. F. W. Langdon 12 
would attribute the production of the syphilitic fever to the invasion of 
the nervous system by syphilitic toxins or its germs. 

The changes which take place in the constituents of the blood 
clearly explain the production of the fever and also of the neurotic 
affections. Syphilitic toxins invade the blood and produce such marked 
alterations in its composition that it must surely cause some morbid 
influence upon the cerebro-spinal system, revealed as neuroses of a 
simple irritative nature. 

Most of the nervous affections are found in late syphilis, of a 
permanent and destructive nature. They consist in a chronic specific 
inflammatory process, with a hypertrophic and hyperplastic nature, 
gummatous production, gummatous infiltration, gumma. This, how- 
ever, is not a primary affection of the nervous tissues, but must be con- 
sidered as an affection of the vessels, either blood or lymph vessels. 
It is in the nature of a peri- and of an endo-arteritis, as we find infiltra- 
tion in the connective tissues forming the tunics of the vessels, and an 
enlargement of the endothelial cells, with a thickening of the lumen of 
the vessels. 

The lymphatic vessels accompanying the blood vessels are the 
channels through which the syphilitic spirochaetse find their way 
to the blood vessels, as it is not very credible that the infection of the 
vessels comes from the main blood stream. In this point of view we 
agree with the opinion of Langdon, 13 who considers the source of in- 
fection in the walls of the blood vessels from the lymphatic vessels in 

9 H. J. Berkeley. " Mental Disease." 

10 Journal Mental and Nervous Diseases, 1898. 

11 Quoted by Gould's Year Book, 1901. 

12 Langdon. "Syphilis of the Nervous System," A. M. A., 1901. 

13 L. c. 



120 THE MEDICAL ASPECTS 

their tunics. Indeed, we know that syphilitic infection in the blood is 
only temporary and due probably only to the toxins, as the blood easily 
finds the way to get rid of them, while the infectious germs of syphilis, 
as Virchow 14 said, remain in the lymphatics, which offer the best cul- 
ture medium for their development. It is only the capillary plexuses 
of the vasa vasorum and in the intramural lymph spaces where a 
syphilitic germ finds the conditions favorable to its development. In 
accordance with these views, syphilis of the central nervous system is 
originated by a lymphangitis, phlebitis, or arteritis, from which an 
exudation of small infiltrating cells arises, small leucocytes of a delicate 
structure without any phagocytic power. They cannot oppose any 
resistance to the invading germ, and on the contrary they constitute the 
natural bouillon where the germ proliferates. These cells are collected 
in masses forming a gummatous tumor, or are spread out in the connec- 
tive tissues in thin layers causing fibrous organization, as in gummatous 
meningitis, diffuse arteritis. These infiltrating cells, however, have no 
right to remain in those tissues and on account of the pressure on the 
blood vessels they remain without nutrition and in consequence die. 
It may also occur that the blood vessels are capable of reabsorbing the 
small infiltrating cells, and take them again into the general circulation. 
In both cases, however, the irritation produced on the connective tissue 
fibers has already caused an hypertrophy and a proliferation of their 
corpuscles, and in consequence they must undergo the natural changes 
due to this process ending in cicatrix or rather in sclerosis. 

It is according to the period of the evolution of the pathological 
process that the manifestations on the nervous system will be of dif- 
ferent order. In case of an endoarteritis or of a thrombosis, which 
prevents the circulation in the blood vessels, the nutrition of the infiltrat- 
ing cells, and also of the tissues of the region must fall into a necrotic 
condition, and areas of softening are the result. Secondary degenera- 
tion of the neuron may occur in consequence of mechanical compres- 
sion of the infiltrating elements. As a result of stasis of the lymph 
in the lymph channels, toxic conditions may arise from different bac- 
teria, which cause local toxic conditions. 

Indirectly, syphilis may be responsible for chronic nervous affec- 
tions resulting from arteriosclerosis, such as paresis and ataxia. 

Syphilis in the late period, either acquired or of hereditary origin, 
constantly produces an infiltration and hypertrophy, which in the form 
of gummatous arteritis or of meningitis affects the nervous system. 
Many cases of infantile hemiplegias, and also of spastic paraplegias, 
recognize this source. Syphilis in children, moreover, is responsible 

14 Virchow, R. " Ueber die Natur der constitutionelle syphilitischen Affec- 
tionen." Virchow's Archiv. 15 B. 



SYPHILIS OF THE NERVOUS SYSTEM 121 

for defects of a developmental nature, and cases of idiocy and of im- 
becility find their cause in a degeneration of the vascular system. 

In the same way, in adults, syphilitic infection affecting the last 
plexuses of the capillary blood vessels in the cortex, is capable of attack- 
ing the various association tracts in the form of minute multiple foci 
of encephalitis, producing syphilitic epilepsy and other psychoses. 

This shows that the action of syphilis on the nervous system is 
quite an extensive one, at times, in the form of thrombosis, causing 
softening with resulting hemiplegia, at other times, in the form of 
meningoencephalitis and meningo-myelitis, causing various psychoses, 
and chief of all in the form of massive gumma with its train of con- 
sequences. 

Syphilis has been considered as one of the most powerful factors 
in the production of multiple neuritis. Dubois 15 has described an in- 
flammation of the sciatic nerve of syphilitic origin. The nerves may 
undoubtedly be invaded by minute gummata, but they may also be the 
seat of irritation or inflammation due to the syphilitic poison. There 
may also be a virulent subacute neuritis analogous to that caused by 
various other infections. In some cases the neuralgic pains may be the 
result of the compression of exostoses and other gross specific lesions. 
In the syphilitic neuritis it seems that the affection is not widespread 
to many nerves, but it is limited to the sciatic nerve, and may sometimes 
be only a reflex pain from spinal meningitis of syphilitic origin. 

LOCOMOTOR ATAXIA 

Locomotor ataxia and paresis are clue rather to degenerative 
changes. In many cases they are attributed to syphilis. But there are 
a few cases where syphilis was not found. In consequence the opinion 
of Strumpell that these alterations are the result of a post-syphilitic 
toxin, which, circulating in the blood, poisons the neuron, cannot be 
consistently accepted. But a much more plausible explanation is that 
of Berkely, 16 namely, that an extensive hyalin degeneration affects the 
arteries and prevents the nutrition of the neuron, causing it to undergo 
a molecular death. In some cases there have been found specific vas- 
cular alterations without gumma, which were the cause of the degen- 
eration of the nervous fibers. It seems that the infiltration takes place 
in the adventitia and in the intima of the arteries with hyaline fibrous 
material which narrows, and in some places nearly occludes their 
caliber. This condition is the direct cause of degenerative nervous 
processes in all its forms. 

15 Quoted by James H. Lloyd, Twentieth Century Practice, Vol. XI. p. v }So. 

16 " Specific Degeneration of the Cortical Arteries." Johns Hopkins Hospital 
Reports, IX, p. 236. 



122 THE MEDICAL ASPECTS 

There is a close relationship between syphilis and insanity, and a 
great interval of time has been found to elapse between the syphilitic 
infection and the onset of insanity. In a series of cases of insanity 
following syphilitic infection, Dewey 17 found : in one, insanity follow- 
ing the infection wdthin two years ; in two, within three years ; in four, 
within seven years ; in three, within eight years ; in two. within nine 
years ; in one, within ten years ; in one, within twelve years ; in four, 
within fifteen years ; and in one, within sixteen years. In one case 
insanity occurred after nineteen years. Dr. Clouston 18 narrates a strik- 
ing case of syphilitic insanity from vascular alterations, in one man, 
twenty-five years after he had been infected. He became subject to 
regularly recurring convulsive seizures, and after a few years he was 
affected with general weakness, partial paralysis of the left side and 
thickness of speech. With enfeeblement and loss of memory, he passed 
into stupor and died. The autopsy revealed the calvaria condensed, 
the dura thickened and adherent to the bone and pia. and the latter 
to the convolutions. A great part of the center of the anterior lobe 
of the right hemisphere and many of its convolutions were atrophied. 
There were found hypertrophy of all the arterial walls and every form 
of irregular local arteritis. 

In some cases, in consequence of syphilitic arteritis, the whole of 
the white substance in the inside of the anterior and middle lobes, lying 
between the outside convolutions and the central ganglia, had gradually 
and entirely disappeared, leaving the gray, matter intact. This is due 
to the different way in which the gray and the white matter are supplied 
with blood, and the much larger quantity which the gray receives. 
Syphilomata produce brain and mental symptoms of a different nature, 
but they may sometimes be affected by treatment and the patient may 
recover. The mental symptoms may be those of an ordinary insanity, 
mania or melancholia, with or without delusions. 

We must call attention to the fact that in some cases of melancholia 
the patients claim to have been syphilitic, and may call the attention of 
the physician to any little pimple, believing it to be the result of syphilis. 
They have never had syphilis, and the idea of being syphilitic is nothing 
but a delusion, a gloomy idea due to melancholia and not to syphilis. 

In some very sensitive individuals the idea of having contracted 
syphilis remains with them, and they cannot think themselves free from 
the disease. They are neurasthenic, a kind of neurasthenia induced by 
syphilis, not of a material order, but only of a mere psychic origin. 
They are continuously hunting for symptoms, and any little indisposi- 

17 Journ. A. M. A., p. mo. 

18 Quoted by Fielding Blandford. " Insanity," Twentieth Century Practice, 
1897. 



SYPHILIS OF THE NERVOUS SYSTEM 



123 



tion is by them referred to syphilis. This condition belongs to the 
class of nosophobias, and is called syphilophobia, which in some cases 
has caused a true melancholia. 

Mobius 19 calls tabes and paresis metasyphilis, and believes that 
they both become more frequent in just the degree syphilis extends. 
He finds both diseases to be essentially one metasyphilis of the nervous 
system, with a difference in the location : when the brain is affected, 
it is general paralysis ; when the centripetal nerve fibers are involved, 
it is tabes. 

But it is necessary to consider that in the largest number of 
syphilitic patients no general paralysis follows, and also that in many 
cases alcohol and syphilis may produce alcoholic and syphilitic insanity 
without general paralysis. In this regard there is a great division of 
opinion among the authors. Some are of the opinion that patients 
affected with insanity have been already predisposed to insanity, and 
that syphilis has very little influence or none at all in the production of 
the disease. Bevan Lewis excludes syphilis entirely from the category 
of the causes. He thinks that many cases of insanity occur in in- 
dividuals who have had syphilis, and some of them have been affected 
with pseudo-general paralysis, which closely represents the true kind. 
In these cases an antisyphilitic treatment may be beneficial in arresting 
the late syphilitic process, and has led to the belief that with anti- 
syphilitic treatment a case of general paralysis has been cured. 

As a rule, the antisyphilitic treatment in general paralysis is of no 
benefit, and it is strongly condemned by Fielding Blandford 20 as very 
harmful. But, indeed, we do not see what the treatment is capable of 
doing in a degenerative affection, where the gray and the white cerebral 
substance has been invaded and starved by the pressure of the increased 
connective tissues. It is the end of a process which affects the meninges 
and the brain in its totality without sparing any organ. In consequence, 
the criterion from the result of therapeutic measures is invalid, and of 
no interest. It is true that congenital syphilis is not a cause of insanity, 
but is a cause of idiocy, juvenile dementia and of different neuroses. 

GENERAL PARALYSIS 

General paralysis in rural districts is found very rarely, but, in 
large cities is quite a common disease. 

In England it is rare among the women of the upper classes, but 
appears much more frequently in those of the lower classes. In fact, 
among the latter we must consider the effects of alcohol and syphilis. 

19 Mobius. "Tabes Dorsalis. Diseases of the Nervous System." Twentieth 
Century Practice, vol. xi, p. 806. 

20 L. c. 



124 THE MEDICAL ASPECTS 

Alcoholism is not entirely uncommon among ladies, and its results have 
been observed in the form of paralysis and dementia, but not as general 
paralysis. Syphilis is rather common among women of the lower class, 
and Blandford 21 says it is so common that if it were a frequent cause 
of general paralysis, the number of female general paralytics ought to 
be larger than it really is. The wonder is that this disease in syphilitic 
women is not more frequent, and for this reason he claims that syphilis 
is but one factor in the causation of this disease. 

In reference to the two diseases, general paralysis and tabes, 
Idelson 22 points to syphilis as a factor of etiologic importance, from the 
frequency with- which they occur in husband and wife. He believes 
this to be an argument in favor of the syphilitic origin of these diseases. 
He has collected 45 cases from the literature, and 5 cases of his own. 
In 47 per cent, of these both husband and wife were paralyzed ; in 20 
per cent, the husband was paralyzed and the wife had tabes; in 13 per 
cent, the wife was paralyzed and the husband had tabes, and in 20 
per cent, both had tabes. At times the diseases occurred simultaneously 
in both husband and wife ; in other cases at long intervals. In most in- 
stances the husband suffered first, the wife succumbing to the disease 
shortly before the death of the husband. Syphilis was confessed but 
thirty-six times in these cases. 

Since Duchenne pointed out the relationship existing between 
syphilis and tabes, the argument of the inefficiency of the antisyphilitic 
treatment was brought forward to deny this etiological connection. It 
was only in 1876, when Fournier, basing his deductions on his statistics, 
expressed the opinion that locomotor ataxia was most frequently caused 
by syphilis. Erb supported his views with a series of 44 cases, of 
which 2"j had a clear syphilitic history. This doctrine was opposed 
by the most distinguished neurologists, such as Westphal, Remak, 
Bernhard, Leyden, and also in France it found Julliard and Charcot as 
opponents. Their strongest argument was that syphilis of the spinal 
cord has a different appearance from that of locomotor ataxia. Gradu- 
ally the study of subsequent cases gave the interesting statistics of L. 
Meyer of Berlin, who found 19 tabetic women, all with previous syphilis. 
Moreover, in 1881 Gowers found 70 per cent, of cases of tabes to be 
syphilitic. In 1882 Fournier was able to produce a series of 117 cases 
of tabes, of which 91.45 per cent, had suffered with syphilis. 

In that number of patients he was able to show that tabes occurs 
only in the tertiary stage of syphilis, and in 85 cases out of 89, it had 
begun after the third year from the infection, and the course of the 
evolution of syphilis had been of a mild type. In 10 cases syphilis had 

21 " Insanity." Twentieth Century Practice, 1897. 

"Idelson. St. Petersburger med. Wochenschrift. 1901, N. 43. 



SYPHILIS OF THE NERVOUS SYSTEM 125 

shown symptoms of some severity, in 61 syphilis had been of a so-called 
benignant type. Of the 200 cases reported lately by Erb only 9 were 
without history of syphilitic infection. Of the 100 cases of tabes re- 
ported by Oppenheim, 59 had no history of infection, and in the last 
statistics of Bernhardt 83 per cent, of cases of tabes were found to have 
suffered with syphilis. 

From the result of these statistic data it is a consequent conclusion 
that syphilis and tabes are related. The objection that tabes is not 
tertiary syphilis does not disprove that tabes is a sequel of syphilitic 
pathological lesions on the nerve fibers of the spina. Mdbius 23 gave a 
detailed exposition of the history of the syphilitic etiology of tabes, 
concluding that in the great majority of cases of tabes it is possible to 
demonstrate the previous existence of syphilis, and tabetic patients 
where syphilitic infection is improbable are very rare. 

It is quite peculiar that in some cases of cutaneous syphilid, where 
we see with our own eyes the lesion to be a late syphilitic one, where 
we see the antisyphilitic treatment make the eruption disappear, yet the 
patient denies any possibility of infection. We are satisfied that the 
affection is due to a late syphilis, and yet we must resort to the term 
of ignored syphilis. We can apply the same reasoning to the few cases 
of tabes where a history of syphilis cannot be found. 

Tabes begins between the thirtieth and the fortieth years, rarely 
before the twenty-fifth, and rarely after the fiftieth year. Yet a few 
cases of tabes begun before the fifteenth year have been referred to by 
Fournier, Gowers, Remak and Strumpell, in all of which hereditary 
syphilis was demonstrated. One case of a tabetic patient at the age of 
seventy-four was reported by Berger, and he had been infected with 
syphilis when seventy years old. 

Tabes is found with more frequency among men than among 
women, in the ratio of 1 to 8, or at least of 1 to 4.4. This has been 
used as an argument against the syphilitic origin of tabes. But accord- 
ing to Mobius, in 50 tabetic women he found syphilis in the great 
majority, and not in a single case was it improbable. In the same way, 
of 32 tabetic female patients of Erb, 14 were certainly syphilitic. 12 
were probably infected, and in only two cases there were no signs of 
infection. 

Tabes is found oftener in private practice than among the poor. 
The greatest number of cases collected by Erb was in private practice. 
He found in 550 of his cases that 324 were merchants and manufac- 
turers, 50 officers, 34 lawyers, 24 professors and teachers, and 1 clergy- 
man. The rarity of tabes among clergymen is quite remarkable, as 
noted by Mobius, and also by Bouchard among the French ecclesiastics. 
23 Neurologische Beitragc, Heft iii. 



126 THE MEDICAL ASPECTS 

That syphilis is related to general paralysis and to tabes is clearly 
shown by the above referred considerations. The age when tabes 
begins is in perfect relation with the time when syphilitic infection 
occurs. A man usually acquires syphilis in early life, just when the 
sexual instinct is most developed and legitimate gratification not 
possible. The infection is spread from prostitutes who, unrestrained, 
infect a number of young men. Men of higher social position marry 
comparatively late in life, and when they have contracted syphilis, they 
take the precaution of postponing their marriage for some years. In 
the larger cities the laxity of morals and the number of prostitutes are 
greater than in country towns, and consequently opportunities to con- 
tract syphilis are more frequent, which is in relation with more fre- 
quent cases of tabes furnished by the larger cities. In the same way 
the classes of men who, in general, must be virtuous are relatively 
spared, while the classes of men who claim to be men of the world, 
are more frequently the victims of this dreaded disease. 

A long interval occurs between syphilis and the appearance of 
tabes. The restoration to health after svohilitic infection is, in general, 
only apparently perfect ; modifications persist which are too slight to 
be perceived, but which nevertheless follow their progressive evolution. 
The syphilitic germ remains dormant, inactive in the lymphatic system 
for a long period of time, and through any peculiar irritation regains its 
activity and shows up in the form of multiple gumma or of a diffused 
inflammatory infiltration, around the blood or the lymphatic vessels, 
and in many cases the preferred tissues are the most delicate of all, the 
nervous center. It is a chronic affection, which will gradually bring 
about its effect. Organic affections are sometimes simple cicatrices, 
which, disengaged from the primitive cause, become autonomous and 
develop on their own account. Thus tabes is a chronic disease, which 
follows syphilis with the interval of many years. The time between 
syphilitic infection and the appearance of tabes may vary from two 
to twenty years. On an average it can be stated that the time which 
intervenes is from five to fifteen years. The same observations can 
be applied to general paralysis. Tabes is a parenchymatous atrophy 
of the posterior cords, and it is not a syphilitic neoplastic infiltration, 
but the atrophy and sclerosis is a consequence of the neoplasy, or a 
necessary end of the evolution. The parts of the nervous system 
which are attacked are not capable of regeneration, the changes there- 
fore are permanent and not susceptible of a cure. 

It has been stated that tabetic patients have had cases of very 
mild syphilis, and Fournier thinks the causation of tabes to be the 
insufficient treatment undergone by these patients. In our experience 
we have found cases of severe tertiary symptoms follow very mild 



SYPHILIS OF THE NERVOUS SYSTEM 127 

cases of secondary syphilis. It is in the cases of benign syphilis that 
the patient, although intelligent and well educated, thinks that the 
continuation of treatment is superfluous as he finds himself in excel- 
lent health. But Fournier himself admits that even patients who have 
had a long and thorough treatment have been later affected with 
tabes. 

The question arises, how is it that of a great number of syphilitic 
patients fortunately only a few are affected with tabes? The answer 
to this question is easily found in the way that syphilis attacks the 
different organs in the different patients. We find that one patient 
will skow the most persistent manifestations in the skin, another in 
the throat; one will have iritis, another will be affected with syphilitic 
orchitis. It seems that syphilis attacks an organ according to the 
continuous stimulus which is applied to it. A man who smokes 
tobacco will show mucous patches on the lips and tonsils ; a man who 
has had gonorrheal epididymitis will in all probability show a syphilitic 
orchitis. In the same way on account of some accessory cause the 
nervous centre may be the point of attack of the syphilitic germs or 
of its toxins. In a neurotic, if he becomes syphilitic, it is possible 
that tabes develops on account of his nervous system being the pars 
minoris resistentice. 



SYPHILIS OF THE ORGANS OF SPECIAL SENSES 

As stated in the beginning of this work, our principal object is to 
treat syphilis from a general point of view ; so we cannot dwell long on 
the syphilitic affections of each one of these org-ans : even to give a 
short description would take us beyond our limits of space. However, 
as the affections of the organs of sense are of the greatest interest in 
reference to the infected, so we will very briefly summarize the prin- 
cipal syphilitic troubles occurring in these organs. 

Sight. This is the organ which in preference to all others is the 
favorite localization of lues. It has already been mentioned that the 
eyelids and the eyebrows are often the seat of papular and papulo- 
pustular syphilides, and in a late period gummatous foci are often 
found in these regions. 

Initial lesions of the eyebrows have been but rarely observed. 
One case was found by Ricord, and Lang refers to a case recorded by 
Morel-Lavallee, where an initial lesion developed on the left eyebrow, 
caused by a bite during a scuffle. We have observed an initial lesion 
exactly covering the glabella in a woman who fell and accidentally 
struck her face on a elass. Initial sclerosis of the lids have been 



128 THE MEDICAL ASPECTS 

quite frequently found on the edge of the lid, on the inner conjunctival 
surface and on the outer skin. 

The manner in which the virus has been carried to the lids is 
different in the reported cases. The initial lesion of the eyelid has 
been observed after a kiss on the eye; in other cases it has been 
caused by rubbing the eyelid with a dirty finger. Lang refers to 
a case of Tepliaschin, where a syphilitic female " healer " was in the 
habit of licking the eyes of persons suffering with ophthalmia, who 
had in this way infected the lids of seven persons. One case of 
chancre of the left eyelid came under our own observation in a 
Russian Jewish girl, who had her eye licked by another person for the 
purpose of removing a small piece of cinder from under the eyelid. 
An interesting case is referred to by Desmarres, where a physician 
contracted an initial lesion of the eyelid from the saliva splashed into 
his face by a syphilitic patient in a paroxysm of cough, while the 
doctor was touching his ulcerated throat. 

In the case of the initial lesion of the eyelids, the trouble is, that 
it is not recognized till late, when it has fully developed and ulcerated, 
and only then does it receive an appropriate treatment. For this 
reason the surrounding skin of the lid is greatly swollen and edema- 
tous, the conjunctiva is red and greatly swollen, to the degree of 
chemosis. 

From the initial lesion of the eyelids, the lymph glands which 
begin to be infected are the preauricular and the submaxillary, which 
are at first either involved separately or together. 

In the evolution of secondary syphilis the eyelids are often the 
seat of papules and pustules, which are found also scattered over 
the surrounding skin of the forehead, nose and cheeks. Papules 
affecting the free edge of the lid, and especially at their angle, soon 
become abraded and ulcerated in the form of mucous patches. The 
eyelashes are often likely to fall off either from the ulcerated condi- 
tion of the edges of the lids or from the general alopecia. 

Gummata affecting the eyelids may remain limited to the skin or 
to the edge of the lids in the form of chalazion. When a gumma 
affects the skin of the eyelid it shows a nodular infiltration, surrounded 
by a dark red or bluish red color, the whole lid is painful and gradually 
becomes swollen, and when the upper lid is affected the eye is closed. 
The process may be acute or chronic, but usually lasts for several 
weeks, ending with ulceration. It heals up, leaving a cicatrix, which 
will usually lead to some degree of disfigurement, on account of the 
contraction of the skin. 

When the gummatous infiltration affects the free edge of the 
eyelids, then we have that rare syphilitic affection of the lids, which 



SYPHILIS OF THE NERVOUS SYSTEM 



129 



was called by Michel and Magawly tarsitis syphilitica. It is in a form 
of chronic indolent infiltration of the tarsus, which does not involve 
the external skin. This, however, is somewhat swollen and edematous, 
and the conjunctiva is also somewhat red and swollen. It looks like 
a hard and resistant tumor, consisting of a homogeneous infiltration 
starting from the tarsus, involving the mucous membrane of the inside 
of the lid, with some complication on the side of the bulbar con- 
junctiva. Under an appropriate treatment, the infiltration gradually 
subsides, and then the eyelid can be turned, showing patches of yel- 
lowish infiltration on the thickened conjunctiva. It is often followed 
by a deformity of the tarsus, the consequence of the pressure and 
destruction of the cartilaginous tissue. 

The conjunctiva is more rarely affected by syphilitic lesions. Only a 
few cases of initial lesions of the conjunctiva are on record, and 
nearly all have been found in physicians, who got into their eyes the 
saliva thrown off by the patients whose throats they were treating. 
In these cases when a hard chancre is developing in the conjunctival 
sac, conjunctivitis and photophobia will follow, and after healing only 
a superficial cicatrix is left. The preauricular and the submaxillary 
glands are enlarged, swollen and indolent. 

Gumma may show up on the conjunctiva, involving the sclerotica 
and also a limbus corneae, in the form of a hard, flat infiltration. It 
may undergo a process of involution and be reabsorbed. In case of 
its ulceration and breaking down, a thick cicatrix in the form of a 
pterigium will deform the conjunctiva. 

It is necessary to state that many of these affections have often 
been mistaken for malignant growths, or for lupous ulcerations, and 
the study not only of the lesion but of the whole body will reveal the 
presence of lues, and throw some light on its nature. 

We will only mention that the carunculse, although very rarely, 
have been found affected by the primary lesion or by gummatous 
infiltration. The tear ducts have been found involved in the syphilitic 
ulcerative products of the neighboring skin. The lachrymal sac and 
ducts have been equally affected in consequence of periostitis or 
ostitis of the bony lachrymal canal. 

Very few observations have so far been recorded relating to 
syphilitic affections of the lachrymal gland. 

Hutchinson called the attention of the practitioners to peculiar 
lesions of the cornea, which appear at a late period of the constitutional 
symptoms, and yields only to an energetic antisyphilitic treatment. 
Corneal affections have been found by Alexander to form 5.48 per 
cent, of all syphilitic diseases of the eye which came under his ob- 
servation. 



130 THE MEDICAL ASPECTS 

It may come in the form of diffuse parenchymatous, or intersti- 
tial keratitis, which is more frequently found as a consequence of 
hereditary syphilis than of acquired lues. In this case it begins as an 
opacity in the center of the cornea extending towards the periphery, 
or more rarely from the periphery towards the center. The opacity 
has its place in the deeper layers of the cornea, and it is not homo- 
geneous, but is made up of small gray or yellowish-gray spots, more 
visible by oblique illumination. It lasts for a long time, the opacity 
gradually being reabsorbed, without leaving permanent alterations. 

The other form of luetic keratitis was described by Mauthner as 
keratitis punctata, and it affects the cornea in the form of a small 
gray spot the size of a pin-head imbedded in the corneal parenchyma. 
These spots suddenly come, and easily disappear, without producing 
any ulceration. 

Cases of gummata of the cornea have been reported, and most of 
them had begun upon the conjunctiva extending towards the cornea. 

The sclerotic is also affected by syphilis, unaccompanied by iritis 
or cyclitis. Mooren, and afterwards Galezowski and Higgens de- 
scribed an episcleritis, and Bull 24 divided the processes of the sclerotic 
into episcleritis, or superficial scleritis, scleritis parenchymatosa, and 
scleritis gummosa. They show as infiltrated patches of the connective 
tissues of the sclerotic, causing the elevation of the conjunctiva. On 
account of a marked vascular injection they are deep red in color 
and formed by the minute congested blood vessels. These patches are 
more frequently found in the vicinity of the ciliary region. Some- 
times an iritis may also be present. The affection is chronic, lasting 
for months. The patches are usually reabsorbed and in the true 
superficial form will not leave any permanent discoloration of the 
sclerotic. 

When, however, the process has affected the deeper layers of 
the sclerotic, the alterations of swelling and of congestion will be much 
more intense. The parenchymatous scleritis does not end in suppura- 
tion or ulceration, but by reabsorption causes an atrophy of the 
sclerotic, which appears as a bluish dark discoloration, making visible 
the pigmented ciliary bodies and the choroid. 

In the gummous scleritis the infiltration is localized, in the form 
of a flat projection, from the size of a lentil to that of a split pea. 
Thev are more often found on the external segment of the eye, and 
on the course of the straight muscle, giving rise to the idea of its 
originating from the sheath of the tendon. They are hard nodules, 
sensitive to the touch, surrounded by congested blood vessels. They 

24 Bull, Ch. S. " A System of Gen. Urin.," etc., " Syphilology," 1893, p. 352. 



SYPHILIS OF THE NERVOUS SYSTEM 



I.3I 









cause pain, some degree of photophobia, and the eye is much impaired 
in its movement. 

Syphilitic iritis is a common affection, which is found at any 
stage of the evolution of the disease. It has been stated that over 
one-half of all inflammatory affections of the iris are of luetic origin. 

Usually only one eye is at first attacked, although the other eye 
may suffer later on. It comes, as a rule, at the time of the papular 
eruption as an early lesion of constitutional syphilis, and it is found 
again with the late symptoms of tertiary syphilis. Iritis has been 
divided into plastic, serous, and gummatous forms. The first two 
forms of iritis have very little to distinguish them from one another, 
but the gummatous iritis or gumma of the iris is characteristic of 
syphilis. 

In some cases of syphilitic iritis, yellowish red points of the size 
of pin-heads can be seen on the edge of the cilia or the pupil, which 
are true papules, and this was called by E. Fuchs iritis papulosa. 
Iritis gummosa is characterized by a small distinct nodular elevation 
on the iris, yellowish in color, affecting the pupillary margin. It is 
the true gumma of the iris, which usually occurs solitary, lasts for 
some time, and usually disappears by fatty degeneration. After reab- 
sorption has taken place there remains a scar on account of the atrophy 
of the iris. It is a lesion of late syphilis. 

Any form of iritis is a grave affection because it may produce 
injury to the function of the eye by the formation of posterior 
synechias or by the occlusion of the pupil. The specific inflammatory 
process may spread from the iris to the choroid, and although rarely, 
may lead to the formation of secondary glaucoma. Syphilitic choroid- 
itis of an exudative type may also appear independently of iritis, and 
it may come as choroiditis centralis. In this case the macula is 
covered by exudation, and later on is changed into a grayish mass 
of connective tissue. Affections of the retina are considered also 
as not rare occurrences in syphilis. 

The optic nerve is, as already stated in the previous chapters, 
usually affected, in case of gumma of the base of the brain or of 
its meninges, in the form of syphilitic optic neuritis, or neuroretinitis. 
For this reason cases of amblyopia and amaurosis from brain syphilis 
are of not infrequent occurrence. 

Hearing. The ear comes next in importance. At the Interna- 
tional Congress of Otology, in 1887, we made syphilis of the ears 25 
the subject of an article, which was afterwards quoted and misquoted 
in nearly every book. Our observations were made in the clinic of 
25 Revue Medicale Franqaise et Rtrangere, Sept. 25. 1880, p. 427. 



I 3 2 THE MEDICAL ASPECTS 

Rome, then directed by Professor C. Manassei. The cases of syphilis 
were in all 144, of which 94 were men, 50 females. Of the 94 men, 
60 were affected with secondary syphilis, and 34 had late tertiary 
symptoms; of the females, 35 had secondary lues, and 15 were in the 
tertiary period. In 144 syphilitic patients, we have found 16 with 
affections of the ears, while in the same number of patients 5 suffered 
with syphilis of the eye, and 4 with that of the larynx. Of the 16 
affections of the ears, 15 were in the form of catarrh of the middle 
ear with an acute or chronic course, the sixteenth was in the form 
of syphilis tuberculo ulcerosa affecting the auricula. Affections of 
the ear have been more frequent in the secondary period than in the 
tertiary, in the proportion of 11 to 5. 

Patients with well developed roseola or papular syphilide have 
never shown signs of otitis externa, or alterations on the membrana 
tympani ; but they were affected w T ith catarrh of the middle ear. In 
6 cases an acute catarrh of the tube and of the middle ear appeared at 
the beginning of the secondary period, and was accompanied by 
erythema faucium, swelling and occlusion of the Eustachian tube. 
Five cases of catarrh of the middle ear developed in a more advanced 
stage of syphilis, accompanying an eruption of mucous patches of 
the tonsils and of the posterior nasal cavity in the vicinity of the 
Eustachian tube. In these cases the catarrh of the middle ear was 
not so acute as in the first cases, but was more persistent. In four 
cases of tertiary syphilis, patients affected with deep gummata suffered 
with catarrh of the middle ear, independently of the condition of the 
pharynx and of the nasal cavity. In these cases there was found 
abundant exudation in the tympanic cavity. Only one case of tuber- 
culo-ulcerative syphilide had affected the auricula and the duct of 
the ear, extending its lesions to the promontorium, with perforation of 
the membrana tympani. 

From these observations conclusions were summarized as follows : 

1st. Syphilis affects the ear more frequently than other organs, in 
the form of acute or chronic catarrh of the middle ear ; 

2d. This inflammatory process in the earlier stage of the secon- 
dary period is mostly due to the inflammation of the pharynx and of 
the nasal cavity; 

3d. In late syphilis a form of idiopathic catarrh of the middle ear 
is produced with peculiar characteristics ; 

4th. In late or hereditary syphilis an ulcerative form of syphilis 
affecting the external ear may find its way to the mucous membrane 
of the tympanic cavity ; 

5th. Syphilitic forms of ear affections, together with a general 
specific medication, require a special localized treatment. 



SYPHILIS OF THE NERVOUS SYSTEM 



133 



In regard to the initial lesion of syphilis on the external ear, it 
is so rare that it seems only two cases are on record. Lues was inocu- 
lated several years ago by a physician in Paris, through the catheter- 
ization of the Eustachian tube in five or six persons. 

Papular eruption when spread all over the body shows also on 
the auricula, and papules in the form of mucous patches not infre- 
quently appear on the concha or at the entrance of the auditory canal. 
Lang referred to the presence of a syphilitic papula on the right mem- 
brana tympani, in a factory girl suffering from syphilis. Zaufal, 
Knapp and Politzer have reported cases of otitis media from the con- 
dition of the Eustachian tube in the course of syphilis. But they do 
not find marked symptoms to distinguish a syphilitic otitis from otitis 
produced by other causes. Gruber has pointed out the syphilitic af- 
fection of the labyrinth, which suddenly and permanently impairs the 
hearing power. It usually affects both sides, though to different 
degrees. 

In cases of cerebral syphilis, especially of basilar meningitis, dis- 
turbance of the hearing may be present. Lane has referred to one 
case of deafness occurring after the appearance of the constitutional 
symptoms, accompanied by weak memory and diabetes insipidus. 

Cases of hallucinations of the hearing are the result of cerebral 
syphilis, as reported by Ayer. In one of our cases the patient com- 
plained of an unbearable noise in his head, which diminished after 
he was affected with hemiplegia. 

The seat of the ear affection has to be carefully determined for 
diagnostic, prognostic and therapeutic purposes. 

Smell. While describing the alterations of the syphilitic affections 
of the nose, especially of the syphilitic ozena, we had occasion to 
mention the bad odor produced, called cacosmia. We haVe also men- 
tioned the results of the destruction of the filaments of the olfactory 
nerves by a syphilitic ulcerative process which causes impairment of 
the sense of smell, anosmia. Cases of cerebral syphilis have been 
referred to where the sense of smell had nearly disappeared. Hal- 
lucinations of the sense of smell have, sometimes preceded attacks of 
convulsions, which as a premonitory symptom gave to the patient the 
illusion of the presence of a pungent and disagreeable odor. In cases 
of basilar meningitis the olfactory nerves have been found involved. 
with diminution or abolition of the sense of smell. 

Taste. Taste may suffer on account of syphilitic lesions of the 
tongue and palate, and as a consequence the obtusion of the sense 



134 THE MEDICAL ASPECTS 

and inability for fine gustatory distinctions follow. As for the sense 
of smell, syphilitic infiltrations may effect compression on the fibers 
of the glossopharyngeal nerve, or of the chorda producing diminution 
of the gustatory sense. Lang referred to the case of Piogey, who 
found loss of taste in a man, who was suffering from neuralgia of 
the third branch of the' trigeminus, who had been infected with 
syphilis twenty years previously. Under the use of iodide of potassium 
the affection improved considerably. 

Touch. The skin is attacked by syphilis in preference to any 
other organ, and in the previous chapters we have briefly described 
the numerous cutaneous eruptions and lesions produced by syphilis. 
As a rule roseola and papular eruptions are ushered in without any 
sensation, but we have had occasion to see patients complaining of 
an unbearable itching sensation on the first appearance of an acute 
eruption of papular syphilide. 

Pain seldom accompanies syphilitic eruptions of the skin, and only 
in some ulcerated gummata accompanied by marked inflammatory 
symptoms does the patient complain of pain. 

In consequence of a syphilitic affection of the nervous centers, 
as gummatous infiltrations, or from altered condition of the blood 
vessels, the sensitive nerves of the skin may show alterations in their 
sensitive functions, in the form of paresthesia or anesthesia. Pares- 
thesia as a state of perverted sensibility, is revealed by burning, sting- 
ing and itching sensations, which closely resemble pain. Paresthetic 
phenomena depend more upon mild forms of irritation of the peripheral 
sensory neurons, and are found in cases of neuritis. In these cases 
syphilis acts more as a toxic agent, irritating the sensitive fibers of 
the roots of the nerves. 

In consequence of more severe affections in the cerebral and 
spinal regions we have seen the skin deprived of its tactile sense and 
become anesthetic. The patient himself does not usually know that 
he has lost in some areas the tactile sense, because there remains a 
subjective sense of numbness. In several cases of paralysis from 
cerebral syphilis where the tactile sense had been abolished, we found 
that the sensation was restored much sooner than the motion. 

In anesthesia not only the sense of contact and the sense of pres- 
sure is lost, but also the sense of temperature and that of pain is 
abolished. In some cases, however, the sensations are dissociated, so 
that we may find abolition of the sense of temperature without tactile 
anesthesia. This dissociation of the tactile sense is not found in 
peripheral lesions, but in deep affections of the gray matter of the 



SYPHILIS OF THE NERVOUS SYSTEM 



135 



spinal cord. The pain sense is associated with the temperature sense, 
and their abolition shows that the terminal sensitive nerves are en- 
tirely cut off from the neuron. 

In a case of progressive idiopathic atrophy of the skin from 
hereditary cerebral syphilis, which we reported one year ago, the 
atrophic patches of skin retained some dull sensation of pressure, but 
the sense of temperature and the sense of pain were greatly benumbed. 



VII 

THE NATURE OF SYPHILIS AS INFLUENCED BY OTHER 
PATHOLOGICAL CONDITIONS 

In medical practice it often occurs that cases of syphilis are 
observed so different in their clinical appearance and in their results 
that they can scarcely be recognized as belonging to the same disease. 
In some cases a patient after having exhibited an initial lesion will 
later show systemic symptoms so mild that at times it seems doubtful 
if he ever had syphilis. While in other cases the symptoms are so 
angry, so severe and so persistent as to produce alterations of the 
different organs with impairment of their functions. 

THE CAUSES OF MALIGNANCY 

In the previous chapter we mentioned that the evolution of syphilis 
has been divided by Ricord into three stages, primary, secondary and 
tertiary. The primary stage comprehends the period from the ap- 
pearance of the chancre to the general adenopathy. The secondary 
period is calculated from the first breaking out of the erythematous 
eruption, roseola spots on the external integument, or on the mucous 
membrane of the palate and tonsils, to the appearance of the superficial 
cutaneous gummata. In consequence this period includes the series 
of symptoms arising from a superficial, irritative process with a ten- 
dency to reabsorption without leaving permanent resulting alterations. 
The secretions from the syphilitic lesions at this stage are highly con- 
tagious. The tertiary period is marked by the tendency to hyperplasia, 
deeply involving the tissues and the organs of the body. The super- 
ficial gummata of the skin, which was also called syphilis tuberculo- 
ulcerosa, would be the line of demarkation between the secondary and 
the tertiary period. At this time syphilis is not so easily communicated 
from the secretion of the broken-down infiltrated lesions. 

The distinction of the evolution of syphilis in three periods has 
been readily accepted by all practitioners, and although an artificial 
one and objectionable in many features, yet we find it of great use- 
fulness. The study of disease cannot be based on exceptions, but on a 
general rule. If in some exceptions we may see tertiary symptoms 
occur at the time when the secondary ought to occupy the phenome- 
nological scene, this is only an exception, which deviates from the 

136 



NATURE OF SYPHILIS 137 

general rule. If in many cases of syphilis we are fortunate enough 
to see only a mild roseolar eruption, a few papules, and then no other 
symptom whatever probably during the whole life of the patient, yet 
this fortunate occurrence will not forbid us to call a tertiary mani- 
festation a gumma, which may come after several years. In order to 
avoid the nomenclature of primary, secondary and tertiary symptoms, 
it has been proposed to make a distinction, in precocious . and tardy, 
or in early and late manifestations. In the same way the resolutive or 
irritative symptoms have been called the secondary, and the ulcerative 
or hyperplastic the tertiary. It is a matter of great importance to 
draw a line between the two orders of manifestations. It is true that 
it is hard to find the place at which to draw this line, but remembering 
the assertion, in natura non datur saltus, we will be perfectly satisfied 
to distinguish the two orders of symptoms. 

In some patients syphilis will have a complete evolution in the 
lightest form, the whole phenomena may consist in a chancre, a mild 
general adenopathy, a scarcely perceptible roseola, and that is all, the 
patient remaining in doubt whether he has had syphilis or not. 

In another patient we find that the syphilitic symptoms follow 
each other with some regularity and with some persistency ; an erythem- 
atous eruption is followed by a papular one, and papules on the 
tongue, or on the lips or on the palate and tonsils are persistently 
relapsing, then after several months the symptoms gradually disappear 
and no further relapse is seen. Both cases may be considered as cases 
of benignant syphilis, the first exceedingly mild, the second somewhat 
more severe. In neither have there been any symptoms showing any 
of the malignancy of the disease ; there have been no ulcers, no result- 
ing scars, no impairment of any organ or tissues. 

In some cases the general health of the patient suffers very deeply 
from the ravages of the syphilitic virus. The patient becomes very 
pale and anaemic, his face is of a sallow yellowish hue, he suffers 
pains, and instead of an ordinary papular syphilide, his body is covered 
with a papulo pustular syphilide. He has that kind of an eruption 
which has been called syphilis varicellaformis, or his body is covered 
with large pustules in the form of ecthyma or rupia, with large thick 
crusts. When syphilis produces these very deep and severe mani- 
festations, we call those cases malignant syphilis. 

This malignancy of syphilis, however, is not so bad and so dread- 
ful as that which we fortunately see in but a few unfortunate cases. 
where after a few eruptions syphilis manifests itself in deep forms with 
profound lesions, ending in destructive results. In consequence we 
find ourselves in the presence of two kinds of malignant syphilis, which 
must be considered separately. 



138 THE MEDICAL ASPECTS 

MIXED INFECTION 

In the first case there is a double infection present, and syphilis 
changes its course and symptoms on account of the simultaneous en- 
trance of the pyogenic elements. In fact, Campana 1 considers the 
suppuration in the syphiloderma as the result of a new septic infection, 
which joins the chronic granulomatous one, as a result of syphilis. 
Tarnowski at the third International Congress of Dermatology main- 
tained that syphilis modifies its course and shows peculiar and severe 
symptoms as the result of the mixed infection of syphilitic virus and 
pus germs. This condition can be revealed at the time of the appear- 
ance of the initial sclerosis, as well as at the secondary and tertiary 
period of the disease. In this case after a short incubation the patient 
is affected with an initial lesion which promptly becomes ulcerated. 
The ulcer discharges abundant pus and detritus, the bottom takes on a 
gray yellowish appearance, the edges are somewhat detached, and an 
edematous condition of the. surrounding parts masks the characteristic 
induration. In these cases the lymphatic glands are soon swollen, in- 
flamed and break down with suppuration. The second incubation is 
a very short one, an intense syphilitic fever soon appears, followed by 
a polymorphous pustular syphilide. In some cases the lesions begin 
in the form of large isolated papules, on which the overlying epidermis 
is soon raised by a purulent secretion, which is readily converted into 
a dark crust. In other cases nodules of the size of split peas are 
formed in the depth of the derma, showing an inflammatory tendency. 
They soon break down, and the pus drying up in masses forms thick 
brown crusts, which cover an ulcerated surface. The ulcers on healing 
leave scars which remain through life. From these papules and 
nodules are originated the different pustular forms which we designate 
as syphilitic ecthyma, impetigo and rupia. 

On acount of the severe symptoms which appear at once, together 
with the general denutrition of the whole system, we consider these 
Cases as of malignant syphilis. Some of these cases with a well-di- 
rected mercurial treatment, together with tonics and reconstituents, 
are soon modified, and the disease takes the aspect of an ordinary case 
of syphilis in the condylomatous period, and is followed by recovery. 
In some other cases, however, the general debility is maintained and 
syphilis from the pustular form soon reaches the gummatous period. 

It is necessary to understand that cases of grave malignant syphilis 

do not originate from others of the same type. On the contrary, in 

cases where both parties could be seen, it has been found that the 

case of malignant syphilis had taken the infection from a case showing 

1 " De morbi sifiliticiee venerei." Genova, 1894, p. 64. 



NATURE OF SYPHILIS 139 

small ordinary mucous patches. In some cases, however, there was a 
purulent discharge from the vagina which could have produced the 
pyogenic infection together with the syphilitic virus. As already re- 
ferred to in this case the initial lesion takes a phagedenic aspect from 
the beginning, accompanied in short time by suppurating bubo. 

In many other cases we find that syphilis has a tendency to 
malignancy during its evolution, although it has begun like any other 
ordinary case. This condition is liable to arise at any time in con- 
sequence of other morbid causes debilitating the general system. The 
development of the microbes of the skin is favored, and they tend to 
penetrate into the integuments on account of malnutrition. 

We will never forget some cases of malignant syphilis developed 
after the injection of Coley's serum obtained from cultures of strep- 
tococcus erysipelas and bacillus prodigiosus. The injections were 
made by a distinguished colleague for experimental purposes. In one 
case a pustular syphilide developed covering the whole body, and 
after getting over this attack, the patient had several relapses in the 
form of rupia. In another case where the same injections had been 
made the patient showed acute pulmonary symptoms, which resulted 
in an abscess of the lung. In this regard Dr. DuCastel of Paris 2 had 
the same experience in the case of a man who had been affected with 
syphilis, but for several years had shown no manifestation whatever. 
He was affected with erysipelas, and was treated with injections of 
the antistreptococcic serum of Marmoreck. When convalescing from 
the erysipelas he showed an eruption of superficial cutaneous gum- 
mata spread in many places on the body, with ulcerations, which still 
persisted after two years. 

These few instances referred to show beyond a doubt that syphilis 
takes a malignant character, not on account of the greater or less 
virulence of its toxic elements, but from circumstances inherent in the 
general condition and the general nutrition of the system. In fact, 
syphilis reproduces morbid manifestations in those organs or tissues 
which were already liable to be affected before the infection ; in a word, 
attacks the pars minoris resistentia?. It is thus that we see nervous 
people affected with syphilis of the nervous system, others easily 
suffering with catarrhal conditions of the throat are annoyed with per- 
sistent patches in that region. It seems that syphilis takes the oppor- 
tunity of all hereditary or acquired predispositions to show its ravages 
in the predisposed organs or tissues. 

In this way we find that the causes of malignant syphilis are 
somehow connected with the systemic condition of the patient : some. 

2 Comptes rendus, iv. Congres International de Derm, ct Syph., par G. 
Thibierge. 



i 4 THE MEDICAL ASPECTS 

however, are the result of his way of living, of his habits, which we 
will briefly consider. 

We have already pointed out that neither the origin of the virus 
nor the locality of the initial lesion has anything to do with the produc- 
tion of malignant syphilis. It is, therefore, due to a predisposition of 
the organism to the pyogenic elements which is the principal factor. 
It is readily understood that all causes disturbing the state of health, 
mechanical, physical, chemical or animate agents ; bad nourishment, 
fasting, overwork, excesses, all these conditions capable of weakening 
the organism are favorable to the development of the infectious germs, 
rendering their evolution more serious. 

TUBERCULOSIS 

Tarnowski refers to cases of malignant syphilis, one in a man 
addicted to alcoholics, another in a patient affected with diabetes, a 
third had been very ill with an attack of typhus, a fourth had been 
affected with malignant syphilis following a case of gastroenteritis, a 
fifth had been exposed to hard labor under a severe moral strain. 

In our experience tuberculosis has a great influence on the course 
and on the malignancy of syphilis. It seems that the tubercle bacillus, 
in consequence of the new syphilitic infection, takes on an extraor- 
dinary activity and in this way syphilis assumes malignant forms. 
Vice versa, tuberculosis, which was latent under the appearance of 
good health, in consequence of the syphilitic infection shows itself with 
quick and destructive results. It is incredible how the two infections 
have so direct an influence on one another, so that when syphilis runs 
a severe course, tuberculosis usually supervenes and ends the life of 
the patient. In some malignant forms of syphilitic phagedenic ulcers, 
it is quite difficult to say whether they are due entirely to syphilis or 
to syphilis and tuberculosis together. These stubborn and destructive 
forms are a hybrid mixture of both infections, limited and localized 
to one part or organ, showing the malignancy and the destructive 
character of the two viruses. The tissues in a debilitated organism 
have no power to resist the ravages of the infectious germs, and in 
consequence undergo the work of destruction without a tendency to 
any reaction. 

ALCOHOL 

In Hospital service, where we have had occasion to see most of 
the cases of malignant syphilis, the most of the individuals are ad- 
dicted to the use of alcoholics. Indeed, in our private practice only 
rarely do we have occasion to see cases of this kind. In the public 
venereal wards of the hospital many of the patients coming from the 



NATURE OF SYPHILIS 141 

lower class are addicted to the use of strong alcoholics, and, when 
infected, syphilis shows a malignant tendency. Chronic alcoholism is 
a powerful agent in producing ulcerative lesions of the skin and mucous 
membranes, and its disastrous effects are also frequently shown on the 
nervous system. Alcoholism hastens the evolution of syphilis so much 
that after a few months the lesions begin to have the characteristics 
of tertiarism. In one of our patients, a heavy drinker, one year after 
the infection gummata appeared on his face, head and nose, which 
ulcerated and left permanent scars. At the same time a gumma of 
the hard and soft palate destroyed that organ, leaving him in the most 
dreadful condition. Alcoholism tends to the localization of syphilis 
in the viscera, liver, kidneys and lungs, which, however, without the 
irritant action of the alcohol, under ordinary circumstances, are usually 
spared by the syphilitic virus. In the same way, patients affected with 
syphilis, continuing the use of intoxicants, are subject to cerebral 
syphilis in all its severe and distressing forms. 

Alcoholism and syphilis are each most effective causes of arte- 
riosclerosis. When, however, they are combined their result is abso- 
lutely disastrous to the system. For this reason, when a man is affected 
with syphilis, he must absolutely abstain from the use of intoxicants. 

TOBACCO 

Next to alcohol comes the use of tobacco, although it does not 
produce so dangerous results. At any rate, starting from the principle 
that syphilitic virus shows its lesions there where an irritation is 
applied, or better in any place or pars minoris resistentia, which is 
already liable to the action of morbid causes, it must be clear that the 
local irritant action of the tobacco will cause syphilitic lesions in the 
mouth, throat and nose, of a persistent and severe type. Syphilitic 
patients continuing the use of tobacco frequently show ulcerated mucous 
patches of the lips, tongue, tonsils and palate. The tongue is often 
affected in the form of extended glossitis with a tendency to ulcerative 
or hypertrophic process. 

Tobacco is often the cause of irritation of the stomach, producing 
catarrh and dyspepsia, and on account of this the patient suffering in 
nutrition is made much more liable to the ravages of syphilis. Further- 
more, a dyspeptic stomach will refuse the remedies, and we will find 
this condition also to be a drawback to treatment. We have- already 
called attention to the production of deep syphilitic ulcers in the 
pharynx of patients addicted to the chewing of tobacco. 

In tobacco has to be considered also a general action upon the 
whole system, in consequence a man affected with syphilis, having his 
system weakened by its toxins, is made more liable to feel the effects 



142 THE MEDICAL ASPECTS 

of the tobacco on the general organism. In consequence tobacco will 
show its action upon the heart and the patient will suffer with a rapid 
heart and become neurasthenic. The injurious effects of tobacco, 
which are not seen in a man in his ordinary state of health, begin to 
be shown in the same man when he is affected with syphilis. Several 
patients have shown symptoms of tobaccoism ; they could not sleep, 
their appetite was lacking, their nutrition was run down greatly, and 
the total abstinence from tobacco helped their treatment considerably. 
Tobacco has also injurious effects upon the eye as well as syphilis, 
in consequence the patient must refrain from the use of the weed out 
of regard of the organ of vision. The bad effects of tobacco on the 
heart and nervous system are counteracted from the use of alcoholics, 
in consequence, in the ordinary circumstances, excessive smokers are 
also addicted to the use of intoxicants, and for this reason, if for no 
other, the abstinence from tobacco has to be enforced with the patient 
during the treatment of syphilis. 

OTHER DISEASE CAUSES 

In general every cause and every condition tending to weaken the 
organism is capable of rendering the character of syphilis severe and 
malignant. Individuals affected with malaria, if infected with syphilis 
may show a case of malignant syphilis, and vice versa a patient already 
infected with syphilis on becoming affected with malarial fever is 
liable to the severe manifestations of malignant syphilis. 

If a man affected with albuminuria, or with diabetes, unfor- 
tunately becomes syphilitic, he is liable to have a severe case of syphilis, 
on account of his previous debilitated condition, and also on account 
of the difficulty of the tolerance of treatment. A great deal has been 
said and written in regard to old age as one of the causes of malignant 
syphilis. It is quite natural to foresee severe manifestations of syphilis 
in old persons as the result of the prevalent arteriosclerosis and of 
the natural debility. Boy-Teissier 3 considers syphilis in the aged 
always grave, terminating speedily in death. All its manifestations 
from the initial sclerosis to the secondary forms are of unusual severity, 
and numerous infiltrations soon appear. The already existing arterio- 
sclerosis, increased by the syphilitic action upon the vascular system, 
soon becomes the cause of deep lesions of the blood vessels and of the 
"heart, so- that death will soon result. Robert W. Taylor 4 in this regard 
says, " A review of my clinical experience has convinced me that in 
rnanv elderly persons of vigorous physique and good habits syphilis 
runs a comparatively mild course, in less vigorous persons it is more 

3 " Old Age." Twentieth Century Practice, New York, 1897. 

4 " A Practical Treatise on Genito-Urinary," etc. New York, 1897. 



NATURE OF SYPHILIS 143 

severe ; and in poorly nourished, weakly and underweight individuals, 
in the nervous, excitable, neuropathic and overstudious, it is often 
severe and even disastrous." 

In our experience we have seen several cases of syphilis taken in 
old age from sixty to seventy-two, and during the time the patients were 
under observation we did not observe any more severe manifestations 
than in younger persons affected with the same disease. We will only 
mention one case of a man at seventy-two who contracted a chancre 
on the glans penis, with all the characteristics of the initial sclerosis. 
It soon showed a gangrenous appearance, and the gangrene affected 
nearly the whole penis. The patient died with septic infection. Other 
cases of syphilis acquired in old age had rather severe symptoms during 
the evolution of the disease, and three cases in our practice were 
affected after the second year with a stroke of paralysis. 

From the foregoing considerations we must see that the virulence 
of syphilis is not clue to the virus itself, but to the condition of the 
infected organism. These may be found sometimes in hereditary dis- 
positions, sometimes in dyscrasia of the general system, either inherited 
or acquired, and finally in the way of living and in the habits of the 
patient. 

The first may be corrected by the physician with a well-directed 
adjuvant tonic treatment, and with well-directed hygienic rules, together 
with the antisyphilitic remedies. The second must be care taken by 
the patient himself to avoid the use of alcoholics, and the use of 
tobacco, and all the debilitating causes which are of great influence in 
the malignancy of syphilis. In consequence, when we find a case of 
malignant syphilis, and we do not find the patient under another 
dyscrasia which has a tendency to make syphilis of a malignant char- 
acter, we must inquire into his manner of living. In many cases we 
will find that poverty and lack of nutritious food are the principal 
cause of the weakening of the system. In many other cases we will 
find that the patient is continuing the use of strong stimulants, is often 
drunk and exposed to the cold air, and has continued in venereal 
excesses. The malignancy of syphilis is a punishment to his reproach- 
able conduct. 

INDIVIDUAL DANGERS FROM SYPHILIS 

On account of a prejudice, which in the olden times arose amongst 
the people against the acquiring of the so-called loathsome disease, the 
practitioners felt some aversion towards this line of practice, fearing it 
would bring discredit upon them. As a consequence, good con- 
scientious physicians neglected this branch of medicine, and quacks and 
charlatans got hold of the patients suffering from syphilis, imposing 



144 THE MEDICAL ASPECTS 

on their ignorance, and taking from them all the money they could. 
Their first task was to fill those unfortunate patients with fear and 
despondency, exaggerating the seriousness of their condition and the 
future results. 

To-day, on account of the development of the auxiliary medical 
sciences, bacteriology and histopathology have thrown light on this 
branch of medicine, the venereal disease was changed into venereal 
diseases, assigning to each one their right nosological groups ; and their 
producing causes have been demonstrated. Therapeutics have shown 
what the remedies can do and what results are obtained. Men of 
integrity, science and ability have worked and are now working on the 
subject; they have brought the study of syphilis and the venereal dis- 
eases to the level of any other branch of medicine, and by showing the 
importance of a rational treatment, they have restored the confidence 
of our patients. 

We can state as a fact that syphilis at the present time is no longer 
so serious and so terrible a disease as it has been in days gone by. 
The judicious and appropriate treatment applied at the right time, to- 
gether with respect to due hygienic rules, has been a great help in 
diminishing the severity of the disease, and also in checking its spread. 

In this regard we will peruse testimonials of great competence, 
brought by Sir Herbert Spencer in his study of Sociology, vol. i, 
page 84. 

The chairman of the late Government Commission for inquiring 
into the treatment and prevention of syphilis, Mr. Skey, consulting 
surgeon to St. Bartholomew Hospital, gave evidence before a House 
of Lords committee. " Referring to an article expressing the views 
of the Association for promoting the extension of the contagious dis- 
eases acts," he said, " it was largely overcharged, and colored too 
highly. The disease is by no means so common or universal, I may 
say, as it is represented in that article, and I have had opportunity since 
I had the summons to appear here to-day of communicating with 
several leading members in the profession at the College of Surgeons, 
and we are all of the same opinion, that the evil is not so large by any 
means as it is represented by the Association." 

Mr. John Simon, F. R. S., for thirty-five years a hospital surgeon 
and now medical officer to the Privy Council, writes in his official 
capacity : " I have not the least disposition to deny that venereal 
affections constitute a real and great evil for the community ; though 
T suspect that very exaggerated opinions are current as to their diffu- 
sion and malignity." 

By the late Professor Syme it was asserted that : " It is now 
fully ascertained that the poison of the present day (true syphilis) 



NATURE OF SYPHILIS 145 

does not give rise to the dreadful consequences which have been men- 
tioned, when treated with mercury. . . . None of the serious effects 
that used to be so much dreaded ever appear, and even the trivial ones 
just noticed comparatively seldom present themselves." 

We must, therefore, conclude, either that the virulence of the 
poison is worn out, or that the effects formerly attributed to it depend 
on treatment. 

The British and Foreign Medico-Chirurgical Review says : " The 
majority of those who have undergone the disease, thus far, including 
secondary manifestations, live as long as they could otherwise have 
expected to live, and die of diseases with which syphilis has no more 
to do than the man in the moon." 

It is stated by Mr. Byrne, surgeon to the Dublin Lock Hospital, 
that " there is not nearly so much syphilis as there used to be," and 
after describing some of the serious results that were once common, 
he adds, " you will not see such a case for years." 

Mr. Surgeon-Major Wyatt of the Coldstream Guards, when 
examined by the Lords Committee, stated that he quite concurred with 
Mr. Skey, and he said : " The class of syphilitic diseases which we see 
are of a very mild character, and in fact none of the ravages which 
used formerly to be committed on the appearance and aspect of the 
men are now to be seen. . . . It is an undoubted fact that in this 
country and in France the character of the disease is much diminished 
in intensity." 

Dr. Druitt, President of the Association of the Medical Officers 
of Health for London, affirmed at one of its meetings, that speaking 
from thirty-nine years' experience, he was in a position to say that 
cases of syphilis in London were rare among the middle and better 
classes, and soon recovered. 

One of the most important testimonies is that of Mr. Jonathan 
Hutchinson, who is recognized as the highest authority on inherited 
syphilis, and to whose discoveries the identification of syphilitic taint 
are mainly due. While under a natural bias rather to overestimate 
than underestimate the amount of inherited syphilis, Mr. Hutchinson, 
while editor of the British Medical Journal, wrote : 

" Although there is an impression to the contrary, yet recent dis- 
coveries and more accurate investigations, so far from extending the 
domain of syphilis as a cause of chronic disease, have decidedly tended 
to limit it. . . . Although we have admitted as positively syphilitic cer- 
tain maladies of a definite kind not formerly recognized, we have ex- 
cluded a far larger number which were once under suspicion. . . . 
We can identify now the subject of severe hereditary taint by his teeth 
and physiognomy, but those who believe most firmly in the value of 



146 THE MEDICAL ASPECTS 

these signs, believe also that they are not displayed by one in five 
thousand of our population." 

In the United States we find James N. Hyde, of Chicago, who, al- 
though imbued with pessimistic ideas in regard to syphilis, wrote, 
" But all said and done, the representative of advance in social science 
should clearly recognize the fact that syphilis is not, as has been claimed 
by a class of hysterical writers in many lands, a scourge threatening 
above all other maladies the devastation of the human family. Tuber- 
culosis annually destroys many more victims. . . . The proportion of 
syphilitic to other diseases in no part of the world exceeds a variation 
of between 2 and 5 per cent, when both sexes are estimated in the 
statistical returns." 5 

The statistics of the United States Marine Hospital Service, for 
the decade 1881 to 1890, inclusive, in a number of patients varying 
from thirty-two to fifty thousand a year, show that the number of 
cases of primary syphilis varies from 3 to 5.1 per 100; secondary 
syphilis varies from 12. 1 to 15 per 100. The percentage of deaths due 
to syphilis to the total mortality varies from 1 to 2.3 per 100. Sam 
Treat Armstrong, 6 after considering the statistics of hospital and of 
dispensary patients for ten years, writes : " In other words, among a 
number of thousands of patients coming from a class of society sup- 
posed to be particularly susceptible to venereal diseases, less than 10 
per cent, of the total number of patients treated were suffering from 
the various forms of syphilis. These percentages show no tendency 
to an increase or to a decrease of the disease during successive years, 
and their range of variation is so moderate that the mean and prob- 
able error of each year is about 1 per 100. Another factor that is to 
be considered is, that there is absolutely no more restriction imposed 
upon these men than there is upon the members of the community at 
large." 

The mortality rate, taking the deaths from syphilis in comparison 
with the total number of deaths from all diseases, for the said decade, 
has been of 1.84 per 100. This means that in 10,000 deaths resulting 
from all kinds of diseases, 184 were due to syphilis. Dr. Joseph 
Schorr (Intern, klinisch. Rundschau Wien. 1888), in an interesting 
paper on syphilis as it occurs in the armies, stated that in the large 
number of 250,589 patients treated in 592 hospitals in Austria, 9.68 
per 100 were suffering from syphilis. This calculation is very near 
to that shown from the statistics of the United States Marine Hospital 
service. 

5 Hyde and Montgomery. " A Manual of Syphilis and the Venereal Dis- 
eases." Philadelphia. 

6 " Syphilis in Relation to Public Health," in " A System of Genito-urinary 
Diseases — Syphil. and Dermat." Edit, by Prince A. Morrow, New York, 1893. 



NATURE OF SYPHILIS 



147 



We find it to be interesting to give the statistics of the City Hos- 
pital of Cincinnati for nineteen years, from 1888 to 1907, and which 
we have collected with the help of our clerk, P. A. Marchand. 

In the large number of 100,713 for the 19 years, the total number 
of cases of syphilis was 7824, which means 13 per hundred, so far 
entirely in accordance with the statistics already given. The death 
rate is also clearly illustrated in the small table; among 100,713 pa- 
tients, there were 9705 deaths, of which 168 were caused by syphilis, 
giving 17 deaths for syphilis in 1000 deaths from other causes. We 
must also remark that in the City Hospital we have two wards pur- 



CINCINNATI HOSPITAL. 








Total number of 
patients for the year 


Total deaths from 
all causes 


Total number 

of cases of 

syphilis 


Deaths from 
syphilis 


YEAR 


M 


F 


Total 


M 


F 


Total 


M 


F 


Total 


M 


F 


Total 


1888 

1889 j 

1890 

1891 

1892 

1893 

1894 

1895 

1896 

1897 

1898..... 

1899 

1900 

1901 

1902 

1903 

1904 

1905 

1906 


4174 
2363 
2559 
2901 
2672 
3128 
3423 

; 3600 
3579 

' 3261 

! 2930 
1 3051 

! 2750 
! 3257 

1 3882 

! 4289 
5217 
5243 
4979 


1411 
1291 

1359 
1284 

1 143 
1307 

1523 
1621 

1675 
1557 
1492 
1658 
165 1 
2126 
2190 
2127 

2155 
2780 
2105 


5585 
3654 
39i8 
4185 
3815 
4435 
4946 
5221 
5254 
4818 
4422 
4709 
4401 

5383 
6072 
6416 
8372 
8023 
7084 


249 
220 

265 
303 
302 
306 

310 

399 
158 
307 
213 
280 
37o 
436 
5i8 
513 
583 
624 
619 


126 
194 
104 
in 
108 
126 
149 
123 
119 
120 
128 
129 

147 
161 
171 
180 
242 
209 
257 


375 
335 
369 
414 
410 
432 
459 
522 
442 
378 
435 
342 
427 
53i 
607 

693 

825 
833 
876 


"3 
72 
94 
72 

83 
161 
214 
177 
148 
99 
75 
229 

275 
169 

217 
270 

34o 
237 
234 


93 

5i 

108 

33 

67 

76 

160 

100 

97 

67 

120 

173 
222 

525 
313 
452 
955 
655 
224 


206 
123 
202 
105 
150 
240 

374 
277 
245 
168 

195 
402 

497 
694 

53o 

722 

1294 

932 

467 


10 

5 
1 

5 
2 
6 
8 
8 
7 
3 
1 
1 
2 
2 
5 
9 
5 

I 12 
10 


3 
1 
1 
6 

5 
7 
3 
4 
2 

3 

1 
2 

5 
2 

5 
11 

1 

4 


13 
6 
2 

11 
2 

11 

15 

11 

11 

5 

4 

2 

4 
7 
7 

14 
16 

13 
14 


Total.... 


67, 258 


33> 455 


100, 713 


6,880 


2,825 


9>7o5 


3,288 


4,536 


7,824 


102 


66 


168 



posely for the venereal diseases for males and females, and no venereal 
disease is refused admittance to the institution. 

In reference to mortality in the United States we find very few 
cases of death reported as due to syphilis, and our figures are perfectly 
in accordance with those of the U. S. Marine Hospital service and of 
other hospitals in Europe. In the statistics of mortality reports, we 
see that most of the cases of death from syphilis occur in infants 
affected with congenital syphilis. It must also be taken under con- 
sideration that in some cases of death, syphilis has been the predispos- 
ing cause, and the disease causing death is accounted for as one from 



148 THE MEDICAL ASPECTS 

other natural causes. This has a tendency to diminish the number of 
deaths from this disease; however, we cannot place a predisposing 
cause, which sometimes is only suspected, as the disease causing death. 

In conclusion, victims of syphilis are scarce, and we can state 
that they are no more than 2 per iooo, syphilis thus killing less than any 
other disease. This proves our statement that syphilis is at present 
no longer so virulent as in former times, that in ordinary circumstances 
it has no bad influence on the longevity of man, and all the dreaded 
consequences are no longer as common as we have found in the past 
generations. 

There is no doubt that this great change which has occurred in the 
nature of syphilis in the last century, is due mostly to the treatment 
and to the facilities with which it can be applied. The heresy that 
syphilis will disappear by itself without treatment has been entirely 
dispelled. The idea that mercurial treatment is the cause of so many 
sufferings, is gradually losing ground to such a degree that intelligent 
patients already know the medicine to be taken and have no fear of the 
alleged dangers. Indeed, we no more find a patient who speaks with 
fear of mercury, and they subject themselves willingly and cheerfully 
to any method of treatment we choose. We can state as a fact that the 
evolution of syphilis depends entirely on the treatment. When 
syphilis is left to itself with no treatment although in the beginning it 
shows very mild symptoms, it will surely lead later to more serious 
troubles, until finally it will reach the time when it will be accompanied 
by conditions of a very grave nature, at times even fatal. We cannot 
declare as a fact that every case of syphilis left without treatment will 
show late manifestations of the tertiary period, but we can say that all 
cases of a tertiary nature with grave symptoms belong to that class 
of cases called ignored syphilis. It is very difficult to find to-day a 
patient who, knowing, or suspecting that he has acquired syphilis, does 
not go to a physician and take some treatment, but cases without 
treatment come from the mild cases of syphilis which had been totally 
ignored. Fournier 7 refers to 221 cases of tertiary syphilis in his 
private practice, with every kind of grave late symptoms, in which no 
treatment at all had been administered. In our experience, in quite a 
number of cases of ulcerated gummata, of deep or superficial type, when 
the diagnosis has been told to the patient, it has been a surprise to him, 
stating that he did not remember having had syphilis in his life. But 
making a more careful examination of the past life, one usually finds 
that in early youth he had seen a small chancre, which the doctor 
cauterized and assured him to be a small soft chancre. There are 
many cases of young married women having had syphilis commnni- 
7 " Traitement de la syphilis." Paris. 



NATURE OF SYPHILIS 149 

cateci by their husbands, and this running a course with very mild 
symptoms., it is ignored on account of the unscrupulous fear that the 
wife may know the truth. It is in this way that we find cases of 
tertiary destructions of the palate, of the larynx, grave affections of 
the eye, of the nervous system, in persons where no suspicion of 
syphilis has ever been expressed. This is the course that syphilis pur- 
sues when it has been left to itself without treatment. Syphilis remains 
latent for many years, but finally breaks out in one or another organ, 
showing its destructive nature at a late period. The idea of the 
spontaneous epuration of the system from syphilis is entirely wrong, 
and the consequences show that the germs of syphilis have no tendency 
to leave the invaded organism. It seems, indeed, as already proposed 
by Virchow, that the syphilitic virus, taking the lymphatic current, is 
transported into the lymphatic glands, where instead of finding an 
obstacle to its progress, it finds a propitious abode and remains there 
undisturbed. The lymphatic glands, although true defenses of nature 
against the morbid invading micro-organisms, yet when the virulence 
of the germs is superior to the phagocytic power of their cells, are sub- 
ject to undergo the overwhelming power of the morbid agent. In 
this case, the morbid agent causing a negative chemiotaxis, finds among 
the young lymphocytes of the cavitary system of the glands a propitious 
ground for its existence. And so it happens that the germs of syphilis 
remain latent for years, and when they find an organ or a tissue in a 
weak condition, as pars minoris resistentice, or when the whole system 
is lacking in its reactive power, they awake from their latency and 
attack that organ with their virulent action. 

Returning to the power of the treatment, which consists principally 
in the administration of mercury in any shape or form, in any com- 
bination, with due attention to its inconveniences and injurious conse- 
quences, we find that it is indeed admirable. Any case of severe 
syphilis, neglected and ignored, as soon as it is subjected to the mer- 
curial treatment yields as if by charm. The treatment must be con- 
tinued for a long time, in fact must be chronic, just as the disease is 
chronic. We see the influence of the treatment so clearly in hospit-^ 
practice, where a patient comes with a syphilitic eruption, and he 
receives a few injections of gray oil or of sublimate, or some mer- 
curial baths or inunctions, and soon the eruption disappears and he 
feels well. He asks to be discharged, and although we try to impress 
upon him the necessity of continuing his treatment, in the generality of 
cases they stop using any medicine, and so in a few weeks or months 
they come back with a new syphilitic recurrence. In private practice, 
on the contrary, where the patient places himself entirely in the hands 
of the nhvsician, continuing in the use of the mercurials, in one form 



150 THE MEDICAL ASPECTS 

or the other, according to his conditions and to the symptoms of the 
disease, we can say that only rarely do we see relapses. We can 
assert that in the patients whom we have treated in the beginning of 
their affection, and in whom we have maintained the treatment from 
two to three years at different intervals, has been scarcely ever seen a 
case of tertiary syphilis. The cases of tertiary syphilis which we have 
had occasion to see have been treated insufficiently, mostly at the 
different springs, where they receive the promise that with a few 
weeks' treatment they will have the syphilis cured. Indeed, such a 
promise is rather dangerous, not only for the future life of the patient, 
but for his descendants. The treatment must be severe, and continued 
for several years, in order to see its splendid results. It is indeed, as 
Fournier says, the antisyphilitic treatment which neutralizes the heredi- 
tary influence of syphilis. Many and many people who had been once 
infected with syphilis, after a good treatment, have been married, and 
now they have healthy and beautiful children. The evil of repeated 
abortions, of children born dead, or which die a short time after their 
birth, in a great many cases must be recognized as the result of syphilis 
insufficiently treated or left entirely without treatment. Fournier 8 
refers to a series of 14 syphilitic patients who by their negligence had 
never been treated. They all married, some communicated syphilis to 
their wives, some did not. From these unions resulted 45 pregnancies, 
with the following results : 

Children living, of whom 6 are syphilitic 8 

Abortions 29 

•Children dying a short time after birth 8 

This frightful statistical table is entirely different from the other 
coming from those who, having had the misfortune to contract syphilis, 
have had the good sense and patience to subject themselves to a long 
and thorough treatment. This is really reassuring, so that according 
to the same author, 9 of 100 children born of parents who were once 
syphilitic but had undergone a severe treatment, only three had died 
from a syphilitic cause. These tables are most eloquent arguments 
for recommending a severe and continued treatment in the early period 
of constitutional syphilis. We can say that syphilis is by the power of 
treatment amenable to recovery. That the treatment stops the progress 
of the evolution of syphilis in its secondary manifestations, and bv 
attacking the syphilitic germ directly, prevents the development of the 
late tertiary symptoms. The diminution of cases of severe tertiary 

8 " Traitement de la Syphilis," p. 17. 

9 A. Fournier. " L'Heredite Syphilitique," 1891. 



NATURE OF SYPHILIS 



151 



symptoms is due to the recent methods of applying the antisyphilitic 
treatment, and to the confidence restored in the patients. The medical 
gentlemen mentioned were right in stating that cases of severe tertiary 
symptoms are not so common to-day as they were several years ago. 
In the same way deaths from syphilis, with the exception of cases of 
congenital syphilis, are rare, and we have demonstrated that they do not 
exceed 2 per 1000. 

This reassuring report that syphilis by means of the treatment is 
diminishing in its intensity must not lessen our efforts to try with 
social hygienic rules to diminish the cases of inoculation, maintaining 
the old saying, prevention is better than cure. 



VIII 
PARASYPHILITIC AFFECTIONS 

To the series of syphilitic affections directly resulting from the 
syphilitic spirilli or from their toxins, another class of diseases 
must be added, what to-day are known as parasyphilitic maladies. 
Fournier called the attention of clinicians and pathologists to a series 
of alterations and manifestations occurring in individuals who had been 
luetic. He recognized syphilis as their principal cause, but the possi- 
bility of other causes is not excluded. Indeed, in these affections 
syphilis is no longer the only morbid factor, but they may arise inde- 
pendently of syphilis from any other cause which is capable of pro- 
ducing the same pathological alterations. From the therapeutic stand- 
point they are to be separated from the syphilitic manifestations by 
the fact that mercury and iodine, which act so well on secondary and 
tertiary lesions, have no influence on their evolution. 

Lesser 1 refers these affections to a special order of the syphilitic 
process, proliferating in character, which does not form gumma, but 
remains a pure interstitial process. It is really related to the gumma, 
but with this difference : in gumma the proliferated elements of the 
connective tissue pass through a stage of regressive metamorphosis 
before producing a cicatrix, and in this process they are gradually 
changed into cicatricial sclerotized elements. They are only a modality 
of the gummatous process, a modality consisting in the regressive 
metamorphosis of the proliferated cells. Gumma and interstitial in- 
filtration go hand in hand, and the first is the result of the second, 
when its elements undergo degeneration. The infiltration of the small 
cells takes place in the interstice of the cellular elements, but the pro- 
liferation takes place in the connective bodies, producing alterations of 
a rather parenchymatous nature. 

The interstitial infiltration is rather difficult to recognize for the 
very reason that so far we have no anatomopathological, histological or 
bacteriological data which will distinguish a syphilitic process from 
another of a different nature. In the study of the skin manifestations 
we are greatly assisted by the clinical appearance, but this process 
affects internal organs, runs a course without pain, is usually localized 

1 Lesser, F. " Zur allgemeinen Pathologie der Syphilis und der sogenannten 
parasyphilitischen Erkrankungen." Derm. Zeitschr. Bd. XI, Heft 9, p. 627. 

152 



PARASYPHILITIC AFFECTIONS 



153 



in places where it does not cause objective symptoms, and is therefore 
obscure and difficult to recognize in its beginning and in its course. 
Indeed, it is so very difficult to make a differential diagnosis of a 
syphilitic gumma of the lungs or of the liver from a solitary tubercle 
of those organs, that in many cases we are compelled to resort to the 
criterion of the special preference of the affections for these organs, 
and to the result obtained by the remedies administered. 

The reasons which prompt us to refer the interstitial infiltration 
to syphilis are first the history of a past syphilitic infection, second the 
coincidence of scars or indurations which remain as the result of ex- 
tinct syphilitic lesions. 

Besides these general anamnestic characters, Lesser takes into 
consideration the locality in some organs which are by preference af- 
fected by syphilis, as the testicle, in the form of orchitis fibrosa, or in 
the lungs as interstitial pneumonia, when tuberculosis can be excluded. 

Another character is furnished by the grouping together in one 
organ of many cicatricial retractions, so as to impart a peculiar aspect, 
for instance to the liver in interstitial hepatitis as hepar lobatum, or to 
the tongue in interstitial glossitis as in lingua lobata. In the same 
way finding the same interstitial process in several organs in the same 
body as hepatitis, nephritis, myocarditis, etc., points out the luetic origin 
as the only factor of the alterations. 

Some light may also be afforded by the anatomical region of the 
affected organ, for instance, the base of the tongue, which is often 
affected with a characteristic atrophy, called by Virchow atrophia 
lsevis basis linguae; the aorta when affected in its arch, as mes- 
arteritis, producing aneurism, and the tibiae when showing those rough 
inequalities which we know as hyperostoses. The age of the subject 
can furnish some diagnostic data, when we consider that syphilitic 
interstitial process of the organs is found usually at an early age, much 
more than is the case from the common causes. Indeed, a cirrhosis of 
the liver at the age of forty will in all probability be the result of lues. 

It must be stated beforehand that the virulence of the syphilitic 
infection has a great deal to do with the production of intense inflam- 
matory irritation in the organic tissues. As a consequence, it will 
awaken an acute reaction on the part of the organism as an active 
chemotaxis, with production of infiltrating elements. On the contrary, 
when the produced irritation is feeble, and the vitality of the system 
is inefficient, a slight chemotaxis and a mild inflammatory process will 
be the result. The reaction, therefore, will be inactive and inefficient, 
the infiltration will be scanty, and it will have rather a tendency to the 
proliferation of the fixed tissue cells, causing interstitial luetic process. 

The interstitial syphilitic infiltrations are usually found in the in- 



154 THE MEDICAL ASPECTS 

ternal organs, their progress as in the case of the gummata is unaccom- 
panied by pain, and does not produce objective symptoms which can 
be of any help for diagnostic purposes. The remains of this process 
are usually found in the internal organs at an advanced age in most of 
the individuals who have been infected with syphilis. Lesser especially 
would go so far as to say that the latent period of syphilis is only an 
apparent and a misleading one. In many cases the disease after the 
secondary manifestations, without showing any gumma, produces the 
interstitial process. This occurrence, of great scientific importance, 
places us in a condition to explain many questions concerning syphilis. 
In fact, we cannot explain in any other way the presence of the prod- 
uct of this process, unless we maintain that the virus many years after 
the infection is still alive and active in the system. In the same way 
it will be interesting to see how efficient the antisyphilitic treatment is 
in reference to the latent gummata and to the interstitial process. The 
presence of this latent process in the system of an infected person who, 
showing no symptoms for years, transmits lues to his children, can be 
found an important explanation for many problems concerning in- 
herited syphilis. 

In this regard we cannot put much trust in the statistics, which 
in a great many instances are not correct on account of the difficulty 
of diagnosis. Gummata of the brain on account of the appalling 
symptoms on the part of the sensory and motor nerves involved, are 
more easily diagnosed. But gummata of the lungs are quite fre- 
quently accompanied by tuberculosis, and as such are noted. In 
reference to the gummata or to gummous infiltrations of the liver, they 
pass quite often for cirrhosis of the liver. Gumma of the kidney and 
of the spleen quite frequently remains unobserved. 

The interstitial syphilitic infiltration is liable not to appear until 
many years after the infection, usually a long time after the gummatous 
period. Infiltrations of the kind are found in post-mortem of subjects 
who for twenty-five or thirty years had been infected with lues. Lesser 
has found syphilitic infiltration in the form of orchitis fibrosa in 31 
cases, and as atrophy laevis basis linguae in 26. In the form of he par 
lobatum it was found in 12 cases; in 10 cases presenting in the form 
of hard callosities in different organs. 

These affections were found accompanied by remains of past 
syphilitic processes, as destructions of the hard and soft palate, scars 
on the bones, and characteristic scars on the mucous membranes. 
Their occurrence is only about 8.6 per cent., but very likely the per- 
centage may increase when we are able to take in many peculiar mani- 
festations of the lungs and of the myocardium, which are separated 
from syphilitic affections, for the only reason that they were not ac- 



PARASYPHILITIC AFFECTIONS 



155 



companied by other clearer manifestations. Indeed, we can say that 
parasyphilitic affections are distinguished with difficulty from other 
affections, which are capable of producing the same results. An inter- 
stitial orchitis will be differentiated from an orchitis caused by mumps, 
only through the existence of old syphilitic lesions, which point out the 
syphilitic origin of the manifestation. 

The lack of reaction to the mercurial and iodine preparations, 0:1 
the part of the parasyphilitic affections, does not exclude their luetic 
origin. When we unfortunately have to do with cases of tabes, or of 
general paralysis, we establish their diagnosis when degenerative 
symptoms of the nervous substance are present, and as the nervous cells 
are not capable of regeneration, so from mercurials and iodides no 
benefit can be expected. 

In this regard we find many authors who still advise antisyphilitic 
treatment as the last resort, in tabes and general paralysis, but many 
others look to this treatment in the mentioned diseases with no con- 
fidence and rather as dangerous. The idea is expressed by comparison 
with the fire, which, when extingished, leaves the ashes ; syphilis has 
been there ; the process, however, is exhausted, and there only remains 
the degenerated tissues. 

By the majority of the practitioners tabes is always considered 
of a syphilitic origin, and it is only one of its final manifestations. The 
neurologists, however, consider that seventy per cent, of the tabetics re- 
cognize a syphilitic origin, and the manifestations of tabes arising from 
lues are favored by a nervous disposition, by alcoholism, and mostly 
by insufficient antisyphilitic treatment. 

The degenerative consequences of lues have a tendency to limit 
themselves to the system of the posterior cords in ataxia, to the pyram- 
idal system in the lateral hemiatrophic sclerosis. When the degenera- 
tion extends to the brain, then we have destruction of the nervous cells, 
hardening of the neuroglia, with the terrible and irremediable lesions 
of general paralysis. 

We must not limit ourselves to parasyphilitic affections, which 
are the result of acquired syphilis, but we must comprehend in this 
large group of maladies those which recognize as their factor inherited 
syphilis. In consequence of an arrest of psychical development, chil- 
dren remain imbeciles and idiots. When physical development is im- 
paired, we have found as a consequence inferiority and degeneration, 
lack of vital resistance and liability to be affected with other disease?. 
In the following chapters we will have occasion to study all the 
anomalies and malformations which are seen at the time of puberty, 
as the result of retarded inherited syphilis. 

The mentioned dystrophies and degenerations constitute marks of 



156 THE MEDICAL ASPECTS 

inferiority for which inherited syphilis is alone responsible. They are 
types of degenerations, which lead to sterility and to diminution of 
the population. 

In reference to the treatment we have already had occasion to 
state that many authors are still inclined to try the administration of 
an antisyphilitic treatment, and they have claimed good results in many 
cases. We have already stated that these affections are not influenced 
by the mercurial or iodid preparations, but it cannot be admitted in 
an absolute way for every case. In retarded inherited syphilis the use 
of mercurials and iodides is attended with a very good action, and 
when continued with perseverance they may have a beneficial influence 
in the physical development of the child. 

Sanz y Bombin 2 referred to three cases of tabes and two of 
general paralysis where he obtained perceptible improvement and a 
standstill of the process, by means of intramuscular injections with 
benzoate of mercury, 5 centigrams every other day, together with the 
administration of iodide of sodium in large doses, continuing for several 
months. 

Syphilis is the modern scourge which causes disasters not only to 
the infected, but to his family, causing degeneration of the race. So 
terrible a scourge must be stopped by any means within our power. 

A perfect knowledge of this disease on the part of the physicians 
is a necessity, and for this purpose clinics, dispensaries and hospitals 
must be opened to the medical student in order to render him as far as 
possible familiar with the different manifestations of the disease. Hos- 
pitals and clinics must be open to the poor patients so that they may 
be treated with care and without expense. 

In this way the poor patients will avoid falling into the hands of 
quacks, who are the pest of society, and detrimental to the welfare of 
the infected patients. 

Syphilitic patients with eruptions dangerous for transmission of 
the disease ought to be detained in the hospital, and they ought not to 
be allowed to mingle with healthy companions in factories or in shops. 
Large numbers of patients are infected with syphilis without any fault 
at all on their part, and this spreading of the dreaded scourge could 
have been prevented if the individual infected with dangerous symptoms 
had been detained in a hospital. 

Physicians as well as patients must be thoroughly convinced of the 
necessity of the continuation of treatment. Treatment which we have 
already recommended must be long and chronic, as the disease is long 
and chronic. 

2 Sans y Bombin, M. " Maladies parasyphilitiques." Cotnpt. Rend., XIV 
Congres Intern, de Medicine, 1903. 



PARASYPHILITIC AFFECTIONS 



157 



Finally, the greatest benefit would be the compulsory medical 
examination of the young man who applies for a marriage license. 
If this wise rule would be established, we would save a great many 
poor girls from being contaminated with syphilis by their husbands. 
If a man applies to an insurance society for a policy, he must undergo 
a strict medical examination. In the same way, when he applies for a 
marriage license he ought to be examined by an expert appointed by the 
Probate Judge, and when he is found infected with syphilis, license 
ought to be refused until he has taken sufficient treatment and the dis- 
ease has become so attenuated that there is no risk on the part of the 
bride. 

We are of the opinion that a law of this kind regulating the mar- 
riage license would contribute a great deal to the stamping out of this 
modern plague. 



IX 

THE INFLUENCE OF SYPHILIS UPON OTHER DISEASES 

It is quite interesting to consider to what extent syphilis does in- 
fluence other diseases, and, vice versa, how they influence the evolution 
of syphilis. This argument was very scientifically approached by 
Neisser, Bulkley, Ducrey, and Hallopeau, at the Dermatological Con- 
gress in Paris in 1900. 1 

The door of entrance of the syphilitic virus is furnished by ex- 
coriations, which may sometimes be the result of vesicles of herpes 
labialis of herpes progenitalis. 

In some cases the syphilitic virus is mixed with other infectious 
germs, as in the case of a mixed chancre, where it is associated with 
the streptobacillus of chancroid, or with the staphylococci of the 
pustules, and both begin their morbid process in their own way. Clini- 
cal observation shows that an infectious disease can run its course in a 
syphilitic individual as an accompanying infection, while in other cases 
it shows that syphilis produces interesting modifications in the course 
of the associated infection. 

Syphilis, or rather syphilitic manifestations, may be associated with 
infections having a local action, as for instance a chancroidal virus or 
pyogenic infections, which, however, have no influence on the general 
evolution of syphilis. Syphilis, on the other hand, may be associated 
with infectious diseases, which, although they have a local action, are 
yet capable of producing general infection, as we have seen when it is 
associated with local tubercular forms or with gonorrheal infection. 
Finally, we must consider syphilis associated with general infections 
with an acute course like eruptive fevers, diphtheria, pneumonia, septic 
fever, etc., or with infectious diseases with a chronic course like tuber- 
culosis, lepra, malaria, etc. 

It is generally known that when the virus producing the chancroid 
is associated with the syphilitic virus, or that when the viruses are 
inoculated successively, a mixed infection results in which the char- 
acters of each affection are at their proper time well marked, and con- 
stitute a difficulty in diagnosis. In some cases it is necessary to resort 
to the reinoculation of the chancre so as to obtain a datum, but the 

1 " IV Congres International de Dermatologie et de Syphilographie." Compt. 
Rend, par le Dr. Thibierge, 1901. 

158 






INFLUENCE OF SYPHILIS UPON OTHER DISEASES 159 

best criterion is to follow the evolution of the morbid manifestations, 
local and general, so as to be able to establish the presence of the syph- 
ilitic infection. 

According to Ducrey, the clinical study, the experimental and the 
histo-bacteriological test show that the streptobacillus of the soft 
chancre does not find in the syphilitic lesion any condition which 
opposes its propagation and development. In the experimental in- 
oculations of the virus of chancroid on the initial lesions of syphilis, 
he has constantly obtained positive results. Furthermore, the histologi- 
cal and bacteriological study of the virus has shown that the strepto- 
bacillus. by its distribution in the tissue elements, and by its histo- 
chemical reaction, does not undergo any change on the syphilitic 
ground, and its development is just the same as in non-syphilitic tissues. 
But it has been observed that a syphilitic initial lesion, when compli- 
cated with chancroid, is very likely to show a necrotic or phagedenic 
tendency. 

An early diagnosis of the mixed chancre is of great interest in 
reference to therapeutics, for the reason that the use of caustics, which 
have a good action on the course of the chancroid, have usually a 
beneficial result on the mixed chancre, while the same caustics remain 
useless on the initial lesion and are very likely rather detrimental. 

The association of pus-generating elements with syphilitic products 
is of the greatest importance in every phase of the disease. With the 
hard initial chancre there may be associated streptococci, staphylococci, 
gonococci, which are capable of communicating unusual severity to the 
lesion. The initial syphilitic lesion, which is made up of an infiltration 
of small cells, on account of maceration of its epidermic cover, has not 
only a tendency to become eroded, but is, in consequence of pus germs, 
changed into a true ulcer. Indeed, from the culture of the exudation 
of ulcerated syphilitic sclerosis, there is obtained a variety of pyogenic 
cocci, which are more abundant when the ulceration is more pro- 
nounced. The same variety of pus cocci are found in syphilitic initial 
lesions of the tonsils, in individuals subject to pyogenic affections of 
these organs, and in the same way in syphilitic lesions of the rectum, 
of the prepuce and of the urethra, especially when a gonorrheal process 
is complicated. Indeed, syphilitic lesions through the presence of these* 
germs are rendered malignant and have a tendency to an ulcerative or 
to a destructive process. Their presence is often the cause of lymph- 
angitis, and the lymph glands becoming secondarily infected are sub- 
ject to adenitis, ending with abscesses. The adenopathy which is 
caused by the syphilitic lesion has a chronic course without any tend- 
ency to an inflammatory process, and when it shows inflammation, this 
is the result of the pyogenic cocci, or of allied micro-organisms. 



160 THE MEDICAL ASPECTS 

The lesions of the secondary manifestations of syphilis, as we have 
already seen, are, according to Campana, greatly influenced by the 
presence of pyogenic elements. To them are due the ulcerative process 
shown by some papular eruptions, and the destructive characters and 
the long suppurations shown by some ulcerative processes of the mouth 
and throat. In the same way there are to be ascribed to the presence 
of the white or yellow staphylococcus, the pus collections which are 
found at the top of the syphilitic eruption in the form of the varicelli- 
formis syphilide. The power of the pyogenic germs is better shown 
in the long suppurative and ulcerative process affecting tertiary lesions 
of syphilis. To them are due the extended gummatous ulcers, which 
we see reach the skin, muscles, bones, etc. We have already seen the 
opinion of Tarnowski, that malignant syphilis is the result of the 
association of the syphilitic virus with the pus-producing germs. So 
far, we do not know the action which these germs are capable of induc- 
ing in the general system, but surely it is one of infection, which has a 
great tendency to lower the vitality of the organism. 

Ducrey speaks of a trichophytic patch of the beard, which had 
found its way deep into the follicles of the hair on account of syphilitic 
ulceration, assuming the appearance of trichophytic granuloma. In 
our practice we have often had occasion to see trichophyton in all its 
varieties on syphilitic patients, but we have never observed any change 
in its course on account of a syphilitic eruption. We have had many 
cases of sycosis in syphilitic individuals, due to syphilis and to the 
staphylococcus in the hair follicles, but we have never found it to be 
maintained by trichophyton. 

In reference to chronic dermatoses, such as eczema, psoriasis, 
lichen planus, ichthyosis, we are not ready to report many observations. 
In our experience it has not been a rare thing for us to have occasion 
to see eczema associated with syphilitic eruptions, and in many cases 
we believe that these have been the cause of the eczema. In some 
women who neglect the cleanliness of the body the presence of mucous 
patches in the crurogenital fold was accompanied with eczema, which 
had its origin in the irritating qualities of the secretion of the mucous 
patches. Eczematous eruptions of the same kind we have found ac- 
company the presence of excoriated or ulcerated mucous patches of the 
angles of the lips. In all the cases we have seen we can state that if 
the presence of the patches had produced eczema, the eczema had 
no influence on their course. The treatment of the patches, together 
with the eczema, in a short time cleared the surface without diffi- 
culty. 

Some syphilitic eruptions in the secondary period, having their 
location on the scalp, forehead, naso-labial furrows, and chin, are. when 



INFLUENCE OF SYPHILIS UPON OTHER DISEASES 161 

accompanied with seborrhea, considered by Unna 2 rather refractory to 
treatment. Indeed, this author recommends the association of the 
specific treatment with a medication capable of treating seborrhoic 
eczema so as to obtain the healing of the syphilitic lesions. 

In our experience we have seen several patients affected with 
psoriasis who had been infected with syphilis, or vice versa, syphilitic 
patients who began to show psoriasis. During the beginning of the 
constitutional period of syphilis, when the patient had erythematous 
and papular eruption, the psoriatic patches had entirely disappeared. 
When the patients began to improve and were free from syphilitic 
eruptions, psoriasis gradually began to reappear. We are still treating 
a psoriatic patient for recurrence of the disease who several years ago 
had a severe case of syphilis, while he has not shown any more syphilitic 
manifestations. 

We have seen cases of lichen planus in individuals who many 
years previously had suffered with syphilis. They were men above 
fifty years of age, and they had been infected with syphilis in their 
young days, so that one affection had no connection with the other. 

In two patients affected with ichthyosis congenita we have 
observed the development of syphilis. The two diseases did not show 
any influence on one another except that at the time of a thick papular 
eruption, the ichthyotic condition of the skin seemed somewhat im- 
proved. When the patient began to improve in his luetic condition, 
ichthyosis returned. 

That syphilis may coexist with gonorrhea is proven every day 
in our hospital service. It is undeniable that the irritation caused by 
the presence of the gonorrheal secretion may predispose to eruptions 
of mucous patches around the genitals, in the ostium vaginae. Only 
very rarely have we found syphilitic manifestations in the os uteri, 
which could have been provoked by the presence of the gonorrheal 
secretion. 

Ricord, Jullien, Reclus, and others maintain that gonorrhea in 
man may predispose him to syphilitic epididymitis, orchitis, etc., which 
is not supported by our observations. Indeed, we have never, or only 
very rarely, seen cases of syphilitic epididymitis or syphilitic orchitis 
starting from a gonorrheal complication. It is true that the old asser- 
tion of the locus minoris resistentice would be there to explain the in- 
fluence of one affection on another, but we have failed to see the 
realization of these cases. 

In cases, however, in which the gonorrheal process becomes gen- 
eralized, as it is in gonorrheal arthritis, it seems that it would have a 

2 Unna P. G. " Syphilis und Eczema seborrhoicum." Monatsh, f. prakt. 
Derm., vii, 1887. 



162 THE MEDICAL ASPECTS 

deleterious influence on the syphilitic infection. Some observations 
have been referred to by Rieu-Villeneuve, and Ducrey believes that 
gonorrheal rheumatism is more frequently met with in individuals who 
have been affected with syphilis. In Ward C of our City Hospital we 
have always on hand cases of gonorrheal and of syphilitic rheumatism. 
We find that there is a great difference between the two affections, but 
some deleterious influence is surely produced by one disease on the 
other. 

Riehl 8 presented a patient to the Dermatological Society of Vienna, 
who had suffered with extensive syphilitic ulcerations. He came back 
to the hospital affected with erythema multiforme and pains in the 
joints. This was regarded by Riehl as a mere coincidence, because, 
according to his views, he did not find any relation between syphilis 
and erythema. Erythema in its multiform or nodose types can affect 
anyone, and it is also possible that it affects some who have been in- 
fected with syphilis. 

On this point Finger could not see a simple coincidence, because 
syphilis can produce lesions very much resembling the erythema multi- 
forme. He has observed cases of eruptions of erythema multiforme in 
syphilitics which were only cured by mercurial treatment. Neumann, 
too, was of the opinion that syphilis can simulate erythema multiforme, 
and the differential diagnosis may be helped by the localization of the 
eruptions. Sachs 4 showed another patient who, together with a 
papular syphilide of the trunk, had an eruption of erythema nodosum 
of both legs. 

The question is whether the coincidence of both affections was an 
accidental one, or whether between syphilis and erythematous forms 
may exist some near relation. Finger seems rather inclined to think 
that some relation exists between them, and he supports this view by 
the observation of cases of gummatous ulcerations of the legs, together 
with nodules of erythema multiforme. The erythematous nodules dis- 
appeared without treatment, while the syphilitic gummata required 
specific treatment to obtain their recovery. 

In 1876 Mauriac mentioned an erythema nodosum in conjunction 
with syphilis. Indeed, the pathology of the erythemata has revealed 
it to consist in a venous thrombosis, thrombo-phlebitis, which are quite 
frequent as a consequence of syphilitic angioitis. 

It is necessary in these cases to be careful not to mistake a scrofu- 
lous erythema for an erythema nodosum. The last easily disappears 
in a few days without ever producing ulceration, while the scrofulous 

3 Riehl. " Syphilis et Erytheme multiforme." Wiener Dermatolog. Gesellsch. 
May 4, 1904. Ref. Rev. Pratique des mal. cutan., etc. No. 3, 1905- 

4 Sachs. Wiener Dermatalog. Gesellsch., May 4, 1904. 






INFLUENCE OF SYPHILIS UPON OTHER DISEASES 163 

erythema or erythema induratum (Bazin) very often breaks down, 
ulcerates, and only with difficulty is brought to recovery. 

The influence of syphilis on the eruptive fevers is also apparent. 
In orphan asylums the children with syphilitic antecedents, when 
affected with measles, scarlet fever, variola, show a higher rate of 
mortality than the others who are healthy. In this case, however, it 
is necessary to take into consideration the weakness of these children, 
who are in poor hygienic conditions, nourished only artificially with 
the bottle. 

Petrowski 5 and Amiel have referred to observations of cases of 
lues where smallpox had been of great advantage in causing the dis- 
appearance of the syphilitic manifestations. Ziffer 6 in the same con- 
nection reported a case of a woman who, while suffering with second- 
ary symptoms, was attacked with a severe case of smallpox ; after she 
got well from variola, the syphilitic manifestations had entirely dis- 
appeared and had never returned. Her husband, also affected with 
syphilis, escaped smallpox, but suffered greatly from the ravages of 
lues. 

Neumann and others speak of the disappearance of macular or 
papular eruptions of syphilis during the course of variola. As a con- 
sequence of these observations, Jourjon and Garrigue have proposed 
the inoculation of variola in cases of malignant syphilis for a curative 
purpose. This proposition does not deserve much consideration. 
Moreover, as referred to by Bulkley, 7 the influence of variola on 
syphilitic subjects would have proved very deleterious on their general 
condition. Bamberger, Stohr, Guntz, and others have observed vario- 
lous lesions to be transformed into sypilitic lesions, and syphilitic ulcers 
to appear foul and necrotic, covered with thick yellow exudation, 
variola pustules accumulated on mucous papulae. 

In spite of all this it seems that syphilis, after an attack of variola, 
becomes somewhat attenuated, an attenuation probably due to the loss 
of serum through the variolous eruption. 

Many observations have been made in reference to the influence of 
erysipelas on syphilis. Ducrey in his experience has seen cases of 
erysipelas which developed in syphilitic patients, and in nearly all in- 
stances when the erysipelas had been rather severe and with hig'h tem- 
perature, syphilitic manifestations of secondary or tertiary type dis- 
appeared and had never returned. Mauriac, too, maintained the bene- 

5 Petrowski and Amiel, quoted by A. Ducrey. L. c. 

6 Ziffer. " Tuberculosis und Syphilis der Lunge nebst Reflexionen iiber 
Misch-infectionen (coincidence of Syphilis and Variola)." Pest. Med. Chir. 
Presse, 1888, p. 762. 

7 Bulkley, L. D. " Syphilis and Associated Infections." IV Congrcs Intern. 
pp. 647-651. 



1 64 THE MEDICAL ASPECTS 

ficial influence of the erysipelas in syphilis, and he formulated some 
conclusions in this regard. He thinks that in cases of syphilis where 
the morbid manifestations of the skin and of the mucous membranes 
are of a mild form, the occurrence of the erysipelas with a feverish 
reaction has to be considered as of beneficial influence. Under the in- 
fluence of the general febrile affection and of the local inflammation of 
the erysipelas, the syphilitic lesions are easily involved and rapidly 
disappear. This beneficial influence is seen not only on the lesions which 
are comprehended in their inflamed area, but it is observed equally in 
those manifestations far from the infected area. 

According to the same author, the organism which has been badly 
damaged and run down from the deleterious action of syphilis, through 
the curative action of the erysipelas is greatly changed, and its general 
condition greatly improved. Consequently the erysipelas would have a 
beneficial influence not only on the existing syphilitic lesions, but it 
would prevent further manifestations in the future. 

Quite often cases of erysipelas in the City Hospital are placed 
under our service. Some of those so affected were also from our ward 
for those affected with syphilis, but unfortunately we were unable to 
see the beneficial influence of the erysipelas on syphilis. We have also 
referred to the deleterious influence of the Coley serum, which was 
injected in some syphilitic patients for the purpose of curing them of 
syphilis. 

We rather agree with Schuster, 8 who does not admit any cura- 
tive effect in the erysipelas, but considers the disappearance of 
symptoms as the result of the high temperature, without any permanent 
benefit. 

We must also remember that Lancereaux stated that patients suf- 
fering with syphilis are more easily attacked with erysipelas, and in 
them it is rather dangerous. In the maternity service, syphilitic 
women after their delivery are more frequently affected with erysipelas 
than the others, and in them it is much more dangerous in its evolution. 
In our experience we also have observed that in cases of puerperal 
erysipelas syphilitic women are more frequently subject to the inflam- 
mation, yet we have not found their mortality very high. In a few 
cases we had under observation we found that they soon became very 
weak, the pulse was quick and feeble, and frequent doses of strychnia 
and whisky were the only remedies to maintain the patients until they 
could recover from the erysipelatous infection. 

A beneficial action of erysipelas on syphilitic ulcers is possible. 
The ulcers have been the door of admission to the streptococci. 

8 Schuster. " Das Verhaltniss des Erysipelas zur Syphilis." Deutsch. Med, 
Wochenschr. Aug. 25, 1887. 



INFLUENCE OF SYPHILIS UPON OTHER DISEASES 165 

In reference to tuberculosis we must consider its influence on 
syphilis in a localized and in a generalized form. Individuals affected 
with lupus, if infected with syphilis, although no syphilitic manifesta- 
tion shows on the lupous patches, are more difficult to cure during the 
syphilitic constitutional evolution. Deutsch, however, refers to a case 
of an eighteen year old girl, affected with a lupous patch on her right 
knee, who contracted syphilitic initial lesion on the right labium, and 
while syphilis was developing the lupous patch healed up. 

In our experience we have seen entirely different results, and we 
have constantly found that the association of cutaneous tuberculosis 
with syphilis is of a severe nature and renders the lesion rather stub- 
born to treatment. We have given some illustrations (page 59), of 
extended destructive ulcers of the vulva, and of the skin of the groins, 
and of the perineum, in some cases involving the anus, in prostitutes 
affected with syphilis and tuberculosis. We have already seen that the 
diagnosis is rather difficult and that the microscope is not of great help, 
because the histological features of the lesion are alike in both morbid 
processes. The treatment, either specific or tending to improve the 
tubercular process, shows no decided effect, as we see on syphilitic 
ulcerative forms. 

It is usually admitted, as we have already seen, that general tuber- 
culosis has a deleterious influence on the course of syphilis. Indeed, 
tuberculosis, although having no peculiar action on the syphilitic pro- 
cess, must nevertheless have a grave influence in producing weakening 
of the organism and a tendency to cachexia. Acute or chronic tuber- 
culosis accompanied by anemia and digestive disorders, in the form of 
phthisis, renders the system extremely weak, and when syphilis is 
mixed with it the individual affected with both infectious diseases is 
fast running down. 

It is generally admitted that syphilitic virus has a decided action 
in wakening the tubercle bacillus, and consequently in provoking the 
evolution of tuberculosis. Neisser referred to the observations of 
Hochsinger, who had occasion to follow in heredo-syphilitic children 
cases of anomalous tubercular affections of a malignant type. He 
found that the lungs did not show signs of syphilitic gummata in 
caseous degeneration, but rather true tubercular lesions. This would 
dispel the opinion that pulmonary lesions are the result of mixed infec- 
tion. Indeed, the two infections together must act severely on the 
frail organism, and the system weakened by the syphilitic virus is 
made a favorable ground for the reception and development of tuber- 
culosis. 

We have had in our practice several cases of syphilitic patients, 
who, affected with pulmonary tuberculosis, have died with a severe 



1 66 THE MEDICAL ASPECTS 

type of this disease. In the few cases which we have had occasion to 
follow, either in our private practice or in the hospital, we have always 
been convinced that each one of these infectious diseases has a great 
influence on the increase of the malignancy of the other. In some 
patients, when affected with tuberculosis, if infected with syphilis, 
this has taken on the character of malignant syphilis. In the same 
way in a patient affected with syphilis, when tuberculosis has mani- 
fested itself it has been of a severe and galloping type. 

From our observations we are not ready to agree with the opinion 
expressed by Portucalis and Abrahams : that syphilis acts favorably 
on the course of tuberculosis. They believe in a kind of specific 
antagonism between the products elaborated in the system by the in- 
fluence of syphilis and those caused by tuberculosis. 

In the cases where an individual affected with syphilis contracts 
another infectious disease it may be that there is only an association of 
the two diseases, and that one affection remains indifferent to the 
other. In these cases, according to Hallopeau, there is rather a con- 
comitance of the two diseases. He explains the concomitance with the 
case of a man who, suffering with secondary symptoms of syphilis, 
with his mouth full of patches, had his superior lip split open by a 
blow. His wound was sewed and it healed by first intention without 
sign of an ulcerative tendency. 

A simple concomitance can be seen in this case of a trauma, where 
syphilis had no bad influence on the reunion of the wound. But an 
indifferent concomitance cannot be seen in the presence of infectious 
diseases, where some influence must be produced by the association of 
the two infectious elements. 

Indeed, we have already seen some influence exercised by the 
evolution of syphilis on the course of psoriasis, ichthyosis, lichen 
planus, which, although dematoses not established in their origin, are 
somewhat affected in their course and manifestations. 

Syphilis may already be in the system when another infection 
takes place, or the system may be already affected with an infectious 
element when syphilis is inoculated. In case of microbic association, 
this could usually happen in the primary and in the secondary period 
of syphilis. If we could inoculate syphilis experimentally in lower ani- 
mals, we could inoculate it together with other viruses of infectious 
diseases, then we could see the modification of their virulence in the 
poduction of toxins and in their pathogenic action. We must, however, 
be content with the clinical observations, and with that which w T e know 
in reference to the local syphilitic symptoms influenced by the pyogenic 
bacilli. In general, we can state that a man suffering with syphilis can 
be affected by other diseases without showing modifications in the 



INFLUENCE OF SYPHILIS UPON OTHER DISEASES 167 

character of syphilis. Indeed, in the exanthematous fevers, the infec- 
tion is only temporary and cannot produce permanent changes in the 
evolution of syphilis, and their influence on the course of syphilis is an 
insignificant one. Mauriac 9 reported a case of a young man who had 
two initial lesions on the penis, and a painful right inguinal bubo. 
Twenty days later he was affected with measles. During the course 
of the measles the chancres healed and the bubo subsided. After the 
seventh day of the measles, at the time of the desquamation, a thick 
papular eruption covered the body and limbs. In this case he thought 
that the measles had hastened the development of syphilis, since it had 
been much quicker than in the ordinary cases. In fact, a papular erup- 
tion had appeared on the twenty-seventh day after the appearance of 
the chancre, while in other cases it takes from fifty to sixty days. 

In reference to typhoid fever there have quite often been observed 
cases of syphilitic persons stricken with typhoid. Jullien 10 saw a well- 
defined syphilitic chancre in a man, who was taken ill with a severe 
case of typhoid, which was not followed by eruption. He quoted Diday, 
who referred to a man affected with primary syphilis, who becoming 
ill with typhoid fever showed the syphilitic eruptions only 120 days 
after. In the City Hospital a young man in D Ward was ill with a 
severe case of typhoid fever. After six weeks' convalescing from the 
typhoid a thick eruption appeared on his body and limbs. We were 
called; to determine the quality of the eruption, which was beyond any 
doubt that of a papular syphilide. The man when admitted did not 
mention the existence of an initial lesion, which soon healed. In this 
case the infection of the typhoid fever must have retarded the eruption 
of syphilis. A short course of treatment brought about the disap- 
pearance of the eruption, and the patient was discharged. The man 
was seen some eight months later and stated that he had not seen 
any more syphilitic symptoms. Bulkley quoted Krim, who had also 
reported a case of secondary syphilis, which disappeared at the onset 
of typhoid fever. In our case we had the Widal test applied with 
positive result. 

We have already had occasion to mention the ravages of syphilis 
in those affected with malaria. Campana, Pellizari and others have 
referred to severe cases of ulcerative syphilis in patients already weak 
from the effects of paludism. Malarial cachexia predisposes to visceral 
syphilis, when the two diseases are acting together. It seems that, 
according to Lepers' 1X investigation, there is no association of the 

9 Mauriac. " Syphilis primitif et syphilis secondaire." Paris, 1890. P. 350. 

10 Jullien. " Traite des maladies veneriennes." Paris, 1899. 

11 Lepers. " Syphilis et paludisme." These de Lille, 1889. Ref. Brit. Journ. 
of Dermat., 1891. 



1 68 THE MEDICAL ASPECTS 

two diseases, because their germs are of a different nature. The 
Plasmodium of the malaria is an aerobic and the syphilitic germ must 
be anaerobic, consequently the morbid activity of the syphilitic germ 
would be greatly increased by the consumption of oxygen by the Plas- 
modia of malaria. This would explain the malignant character assumed 
by syphilis in individuals affected with malaria. 

Leprosy has been found associated with syphilis, both diseases 
showing their lesions. This occurrence, as Bulkley stated, would en- 
tirely dispel the idea that leprosy is only a form of hybrid syphilis. 
So far, positive observations on the lepra bacillus in relation to syphilis 
are lacking. A few observations of mixed infections of lepra and 
syphilis have been reported by Leloir and by Hillis. 12 A peculiar 
hybrid form of syphilitic leprosy has been described by Impey, but his 
observations are not supported by clear cases, nor can they show what 
the relations of the two viruses are to each other. 

It is of vital interest to ascertain whether syphilis has any im- 
portance, or better any possible causation, in the production of cancer. 
Syphilitic ulcers are not infrequently a good ground for the develop- 
ment of carcinoma. Lang 13 referred to a case of carcinoma, which 
developed on the site of a former syphilitic chancre. Carcinomata 
originating from gummata have been observed several times, but from 
a primary syphilitic lesion only two authentic cases are on record. 
One was in the clinic of Lang. There was an induration on the inner 
surface of the prepuce, which was also covered with papillomata. A 
few months after it showed a case of carcinoma, for which he was 
operated in the clinic of Prof. Billroth. Another case was likewise 
reported by Dutrelepont in a woman thirty years of age, who had a 
carcinoma developed on an indurated chancre of the right labium. 
In our practice we have observed only one case of carcinoma which 
developed on a syphilitic ulceration. A man of splendid physique 
came for treatment for a papular syphilide of large type papules. He 
had at the same time an ulceration with a tendency to vegetations in 
the mucous membrane of the right cheek. The ulceration of the 
mouth had nothing to do with the initial lesion, of which he bore 
traces in the sulco balano preputiale. It was a form of secondary 
ulcerated papule made worse by the use of chewing tobacco. The 
proliferation of the ulcer began to be so abundant that it was neces- 
sary to scrape the ulcer in order to reduce the granulations. The 
operation gave relief for only a few days, and then the granulations 
took on extraordinary vegetating power. The microscopic examina- 

12 Leloir. " Traite pratique et theorique de la Lepre." Paris, 1886. 

13 Lang, E. " Acquired Syphilis." Twentieth Century Practice, Vol. xviii, 
p. 36. 



INFLUENCE OF SYPHILIS UPON OTHER DISEASES 169 

tion showed the carcinomatous stroma, and as it had its base on the 
inferior maxillary bone, so another operation was performed removing 
the affected portion of the maxilla, and the whole mass of the affected 
tissues. For a while we were looking for a recovery, but later on 
things changed for the worse and the patient, who was of a very 
sensitive disposition, was found dead in his bed. He had cut his 
veins with a pocket knife and bled to death. 

We have referred to this case while trying to see whether syphilis 
has any influence in the production of cancer. This question, which 
has been quite often treated by Audry, was very carefully approached 
by Etcheverry, 14 who gave a literary report of a number of cases 
where syphilis was associated with carcinoma. According to the 
views of Audry, carcinoma can develop on syphilitic leucoplasic patches, 
or on syphilitic stigmata, or even in individuals who had suffered with 
syphilis. Cases were referred to of the three different types, but the 
question whether this combination of syphilis with carcinoma is only 
an accidental one, or whether there is some relation between the two 
diseases so that syphilis may prepare the ground for the development 
of carcinoma, has not been touched. 

Indeed, we often find syphilitic ulcerations which can easily be 
mistaken for epitheliomata. So much so that it has become a rule 
that in cases of doubt of the existence of syphilis, before operating 
on an epithelioma the patient must first be subjected to an antisyphil- 
itic treatment. The hybridism of syphilis and cancer is not to be 
thought of, but cancer can easily develop on a syphilitic ulcerative 
process or on a scar of a syphilitic ulcer for the sole reason of finding 
a prepared ground. The tissues have no resistance, lack in reactive 
property, and as a consequence they have more receptivity for the 
cancerous germ, which finds an easy ground for its development. 
The same condition exists when cancer is developed on lupous patches, 
where we do not see any relation of carcinoma to tuberculosis, except 
the fact that the tissues are rendered better adapted for the receptivity 
of other infectious germs. In the microscopic specimens of our cases 
above referred to, the syphilitic ground clearly appeared from the char- 
acteristic syphilitic hyperplasia of the blood vessels' tunics. 

We are, however, not inclined to accept the views of Ozenne, 15 
that of a mixed condition of cancer and syphilis forming a well-defined 
pathologic hybridity. The antisyphilitic treatment may improve the 
condition of the ulceration for a short time, but later the cancer will 

14 Etcheverry. "Syphilis and Cancer." Ann. de Derm, et de Syph., 1904, 
Nos. 8, 9. Ref. Derm. Zeitschr. Bd. xii, 1905, p. 621. 

15 Ozenne, F. H. " Du cancer chez les 'Syphilitiques, et de Thybridite cancero- 
syphilitique de la cavite buccale en particulier." These de Paris, 1884. 



170 THE MEDICAL ASPECTS 

continue its destructive course. We consider syphilis as a simple co- 
incident cause, which with its irritating and infiltrating process creates 
partes minoris resistentice, which later on can become affected with 
cancer. The two diseases have nothing in common, neither do we 
find any influence of one on the other ; there is only a possibility that 
a syphilitic ulceration may be the ground for the development of 
cancer on account of its long standing and of its slow ulcerating 
process. 

Hereditary syphilis may be associated with many infectious pro- 
cesses ; in children affected with syphilitic pemphigus, it is not rarely 
that a gangrenous process may develop with the destruction of the 
skin. We have already seen in other chapters the influence of heredi- 
tary syphilis in predisposing the system to other infections, especially 
tuberculosis. It is also true that cases of osteo-arthritis, of osteo- 
myelitis, in the form of coxalgia or of Pott's disease, are often found 
in individuals tainted with hereditary lues. 

In conclusion, we can say that every disease may be concomitant 
with syphilis. Some of them may have no influence at all, each one 
continuing in its course. Some may exercise a temporary influence 
on the evolution of syphilis. Others may give the chance to syphilis 
to bring about more decided ravages, on account of the deteriorated 
condition of the general system. Others finally may become associ- 
ated with syphilis and make up a kind of hybrid form, producing 
more deleterious and disastrous results on the health of the infected. 



X 

t 

THE TREATMENT OF SYPHILIS 

It is natural for the reader to think, from the above considerations, 
that if by means of a good and rational treatment we have obtained 
diminution in the virulence of syphilis, and if through treatment we 
have reduced so much the cases of tertiary lesions, with the same 
treatment reducing and curing the earlier syphilitic lesions which are 
the carriers of the virus, we will diminish the probabilities of the 
spreading of the disease. Alfred Fournier x has been the first to 
establish this important prophylactic rule, which is solely in the hands 
of physicians and has already given such excellent results. In the 
following chapters we will consider all the different rules for the 
suppression of the spreading of the venereal diseases. We will see, 
however, that even with the best will and with the best intentions, 
the system of the regulation of prostitution either by the police or 
by the city authorities is inadequate. The strict rules of the police 
tend to diminish the number of public houses, but on the other hand 
tend to increase clandestine prostitution, which is undoubtedly the 
most dangerous for the spreading of syphilis, and for this reason all 
the rules come to an illusory result. In fact, when prostitution leaves 
the public houses, there is an increase in the number of puellse fre- 
quenting concert halls, back rooms of the saloons, etc., which they 
use for .assignation purposes. Experience shows that the rules of 
the city authorities, of the board of health and of the police department 
to restrain and regulate prostitution are not only inefficient, but in 
many cases injurious. 

Syphilis is at present just what it has been in the past, an ulcer 
on the body of society; but we can say, judging from statistics, that 
in these last twenty years, if it has not diminished much, it at least has 
not increased. We agree with Fournier that we find syphilis in every 
place, in hospitals, clinics, infirmaries, insane asylums ; yet on studying 
the statistical reports of American cities for the last ten years, the 
number of syphilitic diseases keeps nearly the same proportions. 

There is no doubt that the most powerful means to prevent the 
spread of syphilis is a well-directed treatment of the disease. Through 

1 Fournier, A. " La Prophylaxis de la Syphilis par son Traitement." 
Bulletin de I' Acad., 1899. 

171 



172 THE MEDICAL ASPECTS 

treatment we succeed in freeing the infected patient from syphilis and 
at the same time we protect society from the spreading of the infection. 

After having recognized the treatment as one of the most effective 
ways to diminish the possibility of infection, there comes as a conse- 
quence the necessity of an easy access, especially for the poorer classes, 
to the benefit of the treatment. For this purpose we have hospitals and 
clinics. Fournier, and we with him, find the hospital a very good 
institution for the treatment of syphilis, but this only in the case of 
severe symptoms, when it is necessary for the patient to rest in bed, 
have careful diet and special nursing. 

In the City Hospital of Cincinnati we have two wards, C and O, 
purposely established for venereal and syphilitic patients. Ward C is 
the male department, and O is for females. In regard to syphilis, we 
admit patients affected with the initial chancre, as well as those 
affected with syphilitic gummata. It is our rule to keep patients 
affected with syphilis in the hospital just so long as they have no 
lesions capable of transmitting syphilis. For men we have no coercive 
rule to keep them in the hospital except persuasion, and with a few 
kind words we succeed in having them remain until we are ready to 
dismiss them. On the contrary, for the females, especially when they 
have been sent from the health department, we have the right to 
compel them to remain so long that they can be discharged as free 
from lesions dangerous for the spreading of syphilis. 

Syphilis, however, is a chronic disease, and at any moment may 
show up in the form of patches in the mouth, or in any other way 
dangerous to others, and it takes years of constant treatment before 
we can consider lues entirely eradicated from the system. It is, there- 
fore, impossible to keep the hospital patients for so long a time, and 
moreover they can continue their treatment while pursuing their occu- 
pations. In this case the patient needs some medical advice, and for 
them the public clinics, dispensaries of the colleges, etc., prove very 
useful. 

Fournier vividly described the clinics for skin diseases and syphilis 
attached to the Hospital St. Louis in Paris. That big gloomy hall, that 
large table where is the chief of the clinic and the assistant physicians, 
the surrounding benches where are students and physicians and visitors, 
enough to make a bad and depressing impression on the patients. 
Moreover, on account of the number of patients, they must sometimes 
wait two or three hours before being admitted. The most of the 
patients come from the class of the working men, and the long wait 
means half a day or one day lost. The patient is compelled to disrobe, 
and half naked make his appearance before the public. When af- 
fected with syphilis, he must confess his guilt, sometimes before forty 



THE TREATMENT OF SYPHILIS 173 

or fifty people. The physician in charge, after having seen many 
patients, is tired out, wishes to be through with his work, and limits 
himself to giving a prescription and telling the patient to come back 
in one or two weeks. 

Fournier justly condemns this system of clinics as injurious and 
dangerous. In many instances the patient has been only once in the 
clinic, he has heard his sentence of being infected, has received his 
prescription, and has continued with the pills prescribed for a few 
weeks, has become somewhat better, has left off treatment and has 
never been courageous enough to think of going back again to that 
gloomy room, and losing half a day of his wages. This man will be 
a source of contagium, will spread syphilis without care, and it has 
happened that his intended bride has been infected with chancre on 
her lips through a kiss. When questioned by Fournier how he could 
kiss his sweetheart when he had this inoculable disease, for which he 
had been to the clinics, he replied that nobody had ever told him that 
the disease was contagious through kissing. 

In another case where the man had inoculated his wife, both 
syphilitic parents brought to Fournier a miserable looking creature, 
the offspring contaminated with congenital syphilis. When asked how 
he could have gotten married while having this disease, the father 
replied that neither in the clinics nor in the hospital had anybody ever 
told him that he could not marry. 

Another case where a syphilitic child of syphilitic parents was 
given to nurse to a healthy woman, the woman developed a hard 
chancre of the nipple from suckling the babe. When the father was 
reproached for his carelessness, he said that nobody had told him 
anything in reference to the danger of infection. 

It is, therefore, a duty of the physician to instruct the syphilitic 
patient on the dangers of communicating the disease to others. It 
is his duty to place before the eyes of the patient the principal ways 
of the transmission of syphilis, not only through sexual intercourse, 
but through kissing, through utensils, pipes, towels, etc. Speak to 
him of the impossibility of getting married on account of the danger 
to his wife and then to his children. 

In this way the work in the clinics will be efficient and will result 
as a preventive to the spreading of syphilis. This can be done, how- 
ever, only in small clinics, when the number of patients is limited and 
the physician can afford to give a few minutes to explain to the 
patient the nature and the dangers resulting from his affection. 
Fournier therefore condemns the system of the large clinics and 
advocates the establishment of small ones. 

We must say that we entirely share in the opinion of the illustrious- 



174 THE MEDICAL ASPECTS 

teacher, and in the principal cities of the United States we follow 
exactly his ideas. The clinics are independent of the hospitals, and 
by law the hospitals in Cincinnati are forbidden to have an out-door 
clinical department. The clinics are dependent on the medical col- 
leges and the professors of the different departments are the chiefs of 
the clinics. These clinics are for the benefit of the students of the 
college, and as an inducement to the patients, the remedies are dis- 
pensed free of charge. There are other clinics attached to charitable 
institutions, where patients are treated free of charge ; but with these 
we are not familiar. 

One of the interesting points to be explained by the physician to 
the syphilitic patient is that the disease, though perfectly curable, 
takes a long time, and requires a treatment continued not only for 
months, but for years. That the disease is contagious and through 
scratches, abrasions, small rhagades, cracks, is inoculated from the 
infected to the healthy individual. In this regard the syphilitic patient 
must abstain from any sexual relation with a healthy individual in 
order to avoid inoculation. When affected with mucous patches, 
abrasions of the lips, tongue and throat they must not kiss anybody, 
especially near the mouth, on account of the danger of communicating 
syphilis. They must exercise care in not allowing anybody to use 
anything which, soiled with the products of the secretions, may com- 
municate the disease, such as pipes, forks, spoons, glasses, towels, etc. 

The patient must be told that syphilis is not only contagious, but 
is also hereditary, and as a consequence a man who has been infected 
with syphilis cannot marry unless he has undergone a good, methodical, 
and often repeated treatment for three or four years, and a few months 
before he must be visited by his physician and obtain his consent, 
which will be given when no more signs of the disease can be found. 

The patient must realize that if married when still under the in- 
fluence of the disease, although having no lesions which can com- 
municate the disease to his wife, the fetus will be contaminated and 
through utero-placentary circulation the wife will be infected. His 
children when coming into the world infected with syphilis, will be 
a source of possible infection, and the nurse or anybody else having 
contact with the child may be easily infected. 

Another advice to impress upon the mind of a syphilitic patient, 
and upon which Fournier insists so much, is that the patient must 
always tell a physician in case of any illness, that he has had syphilis, 
in order to cast light on the nature of the affection. 

Fournier is of the opinion that a small printed card with these 
few instructions distributed in the clinics to the patients affected with 
syphilis would have a beneficial effect for the public. Azua, who has 






THE TREATMENT OF SYPHILIS 175 

charge of the clinic in the Hospital de S. Juan de Dios in Madrid, 
has had these few points printed as avisos sanitarios, and they are 
given to the syphilitic patients coming to the clinic. In our clinic we 
limit ourselves to explaining to the patient the disease which he has, 
the danger of its contagiousness for others, and its hereditary tendency 
for the children. 

In our clinic of the Medical College of Ohio, a department of the 
Cincinnati University, the patient is inscribed in the regular book by 
one of our assistant physicians, who writes the diagnosis, a few points 
of interest and the treatment. At the same time the patient receives 
a card, which has a number corresponding with his number in the book. 
In this way by the number, without writing anything on his card, the 
assistant reads the diagnosis and treatment given on the last visit. 

We must say that we do not meet with all the difficulties and 
troubles complained of by Fournier in the polyclinics. It may be the 
different nature of the race, it may be the education, but our patients 
have no objection to being examined before the class and to being the 
subject of a few remarks on their case. On the contrary, they are so 
interested that after we have made a little explanation to the students. 
they ask for more information, showing that they have followed the 
remarks with attention. 

The patients in our clinic come before the class as they are 
dressed, and very likely they would object to disrobing in another 
room and coming into the clinic room naked. One patient at a time 
goes to the desk of one of the assistants, who writes down his name 
and the generalities, and asks also what the trouble is from which he 
is suffering. Cutaneous diseases and syphilis are treated together, 
and this makes it more pleasant for the patient who is afflicted with 
syphilis, since he can say that he comes to be treated for a skin disease 
In our clinic we have never found a patient who has objected to 
loosening his clothing and showing the eruption by degrees, first the 
chest and back, then the thighs and legs, or first the genitals and then 
the chest and back. In our experience we have always found objection 
on the part of the patient when directed to come into the clinic room 
entirely naked, and on the contrary they have never objected to re- 
moving the clothes or the wrap in the presence of the students. 

We divide the students into classes of twelve or fifteen for daily 
attendance at the clinics, changing about in order not to have the room 
crowded. 

It is a necessity to have in the clinics young physicians who intend 
to pursue special studies in the branch of diseases of the skin and 
syphilis, and from them we usually select our assistants. In the final 
examinations we require the candidates to answer several questions on 



176 THE MEDICAL ASPECTS 

syphilis and on its treatment. Syphilology is a special branch of medi- 
cine, and as such requires a specialist, a man who has given time to this 
study, who has acquired a special experience on the symptoms and 
complications of syphilis, and who is able to institute a special scien- 
tific treatment. 

Unfortunately, the advertisements of the so-called quacks, or 
better, charlatan doctors, in the daily newspapers are of such a nature 
as to impede our work of protection from syphilis. Their advertise- 
ments are based constantly on the old popular prejudice against mer- 
curial preparations. In our opinion reputable newspapers ought to 
refuse advertisements of the following character : " I am the only 
doctor who cures syphilis without mercury." " Take only my vegetable 
pills and they will cure you in three months." or, "I cure syphilis to 
stay cured," etc. Bombastic statements of this kind are dangerous for 
the public on account of increasing superstition, and at the same time 
the guarantee of sure cure causes the patient to quit treatment, and 
hence we see later on syphilitic affection of more severe and of deeper 
nature. It is an unpardonable carelessness, to say nothing stronger, 
that newspapers of high repute allow in their pages such ridiculous 
advertisements, which are purposely given out to cheat and defraud 
the people, with disastrous results for the public welfare. In some 
instances we have seen young men who have had no syphilis go for 
a trifling herpetic eruption to the advertising quacks. They were 
frightened in regard to their condition, and were treated for some 
time for a disease which they never had. In one case of gangrenous 
stomatitis, the patient had been treated by a man who advertises that 
he cures syphilis with a decoction of herbs, and when the patient came 
under our treatment gums, mucous membrane of the mouth and parts 
of the tongue were a gangrenous mass. 

Many and many patients come under our observation affected with 
late symptoms of syphilis, and when we tell them that their trouble is 
syphilis they will hardly believe it for the reason that someone had 
guaranteed to them a sure cure, and asserted that they were perfectly 
cured. 

The reader can easily imagine the sad consequences that asser- 
tions of this kind must produce in reference to the spreading of syphilis. 
When a man is persuaded that he is cured, he neglects any other treat- 
ment, and under this persuasion he will get married, infect his wife, 
have infected children and all the troubles which we have spoken of, 
besides those we will consider later on. 

We are positive that if the editors of reputable newspapers knew 
the sad consequences which advertisements of the kind have on the 
health of the man who is infected and on the future of his family, 



THE TREATMENT OF SYPHILIS 177 

they would surely decline to accept and publish such misleading state- 
ments. Statements promising a sure and permanent cure can be given 
out solely by charlatans, who with bold effrontery for the sake of 
their venal interest, try to take all the money from the ignorant patient 
who trusts to their hands his health, his family, and his future. Those 
vultures of society, whether doctors or not, who speculate on the 
venereal diseases for the sole purpose of obtaining money from the 
patient who is ignorant of the affliction and ashamed to make a con- 
fession to a reputable physician — these quacks ought to be stamped 
out as the most dangerous means of the spreading of syphilis. 

We can say that physicians learned in the subject of venereal 
diseases and syphilis will be of the greatest help in checking their 
spreading. Prof. Kaposi, when speaking to the Congress of Brussels 
on the subject, — " What rules must we take to oppose the spreading of 
syphilis and of venereal diseases,' 3 stated that no matter what rules the 
authorities or the police would choose, the most important point of the 
struggle is always in the hands of the physician. He concluded that 
one of the best means to check these diseases was to institute in all 
the medical faculties clinics and dermatological institutes purposely 
for the study of syphilis and of the venereal diseases. Furthermore 
that these branches of medicine should be made the subject of obliga- 
tory examinations. 

In our medical colleges we have now the chair for Dermatology 
and Syphilology, and the chair for Genito-Urinary Diseases. The 
students are compelled to attend these clinics and at the end of the 
fourth year they must pass the examination on these medical sciences. 
The examinations consist in answering in writing five questions in der- 
matology and five questions in syphilology. In the same way in the 
State examinations there are always given three questions on subjects 
concerning syphilology, so as to ascertain just how familiar the young 
physicians are with the knowledge and the treatment of so important a 
medical, branch. This has been the only way to interest the young 
physicians in attending clinics and lectures in dermatology and syphil- 
ology. We were the first to lecture on these subjects in the medical 
colleges of Cincinnati and to institute clinics and laboratories for this 
purpose, and to-day we have the satisfaction of seeing the good results 
obtained after twenty years of constant work. 

EXTERNAL TREATMENT 

It would be foreign to the purpose of this book to give a detailed 
description of the treatment of syphilis, which is fully given in all 
text-books. We will limit ourselves to sketching our ideas for the 



178 THE MEDICAL ASPECTS 

treatment of this disease, and for the way in which we- treat our 
patients in the hospital and in the clinic. 

Our treatment is local, and general or constitutional. 

Patients apply to the clinics with initial lesions already developed. 
In most cases the lesion looks angry and inflamed for the reason that 
the patient has been to a druggist, who has given him a piece of nitrate 
of silver, or of sulphate of copper, with which he has badly cauterized 
the chancre and the surrounding skin or mucous membrane. In con- 
sequence the prepuce is swollen, edematous, forming a phimosis, so 
much so that if the chancre is in the internal surface of the prepuce 
or up on the glans, it can scarcely be seen. In cases of this kind the 
glands of the groins are involved, painful and greatly swollen ; the 
patient can hardly walk, and he is referred to the hospital. He needs 
rest in bed and we use continuous bathing with a solution of corrosive 
sublimate, i to 2000, to 1 to 1000. The solution is also injected through 
a syringe between the prepuce and the glans. And in twenty-four to 
thirty-six hours the inflammation has subsided, the prepuce can be 
retracted and the ulcus can be easily treated. Then we begin the 
applications with emplastrum hydrargyri, which is prepared as fol- 
lows according to the formula of the British Pharmacopoeia : 

Hydrargyri 3ii 

Terebinthinae 01 wxx 

Cerae Flavae 3 i 

Resinae 3 i 

Styracis praepar ' 3i 

Emplast Plumb 3i 

It is an ointment of soft consistency and is easily spread on a 
piece of gauze and applied on the chancre. It is very effective and 
by a process of suppuration produces the involution of the infiltration 
in a short time. It must entirely cover the borders of the lesion, and 
must be changed two or three times a day. In our clinic the patient 
receives a bottle of solution of bichloride, 1 to 1000, for washing, 
and a quantity of emplastrum hydrargyri. When the inguinal glands 
are enlarged, when the syphilitic bubo is pronounced, we advise our 
patient to apply a piece of cloth covered with the same plaster on both 
inguinal regions. Emplastrum hydrargyri can be employed in this 
way for the initial lesions in any part of the body, and also for an 
endourethral chancre it can be used by making a kind of bougie with 
a piece of gauze saturated with the plaster. 

In cases where the prepuce is narrow and it is difficult to treat the 
chancre, we resort to circumcision. When the glans has been exposed 
we have found a bad-looking chancre showing gangrenous patches. In 



THE TREATMENT OF SYPHILIS 179 

these cases we return to the applications of continued sublimate 
bathing, and then dressing with iodoform gauze until the surface is 
thoroughly clean. 

In some cases where the enlarged glands are greatly hypertrophic 
and tender, we remove them on both sides. The results obtained have 
been gratifying, and as we have already remarked in an article on 
syphilitic bubo, the removing of the glands has a favorable influence 
in the evolution of syphilis. In fact, in most of the cases so operated 
on, the constitutional symptoms of syphilis have come much later, and 
the eruption has been so very mild that it could scarcely be noticed. 
After having removed the glands the only local trouble following has 
been some edema of the penis and of the scrotum, which has lasted 
from one to two weeks, and has then disappeared with the healing of 
the wound. 

We do not believe the cauterization of the chancre to be of any 
benefit, and for this reason we have entirely abandoned this method. 
When the initial chancre is in a place where applications of plaster are 
impossible, as in the oral cavity, tonsils, etc., then we touch up the 
chancre with a solution of one per cent, bichloride of mercury in 
alcohol and ether, as used by Lang, or with a three per cent, solution of 
acid nitrate of mercury. 

In the past we have quite frequently employed excision of the 
hard chancre, with the view of preventing the development of syphilis. 
The excision of the hard chancre was at first recommended by John 
Hunter and Benjamin Bell, who considered the chancre as a local af- 
fection. They maintained that general infection followed its appear- 
ance after some time, making in this way possible the destruction of 
the syphilitic virus, by the early removal of the initial lesion. In the 
clinic of Prof. Auspitz we saw many cases of excision of the hard 
chancre, but the results in most of the cases were negative. Auspitz, 2 
however, maintained the opinion that initial sclerosis was only a local 
symptom, and that the removal of the chancre was the true prophylactic 
means. He published on this subject an article referring to 33 cases 
of excision of the hard chancre, claiming success in 14 cases. Since 
then hard chancres have been excised by hundreds, so much so that 
Dr. Crivelli 3 was able to report 454 cases of excision of hard chancre, 
and Ehlers 584.* 

2 Auspitz, H. " Ueber die Excision der syphilitischen initial sclerose." 
Vierteljahresch. fur Derm, und Syph., 1877, p. 107. 

3 Crivelli. " Des signes precoces de l'infection syphilitique, comme contra- 
indication du traitement abortif de la syphilis." Arch. Gen. de Median, 1887, T. 
i et ii. 

4 Ehlers, E. " Extirpationen af den syphilitische initial Lsesion." Copen- 
hague, 1891. 



180 THE MEDICAL ASPECTS 

The idea of the bacillary origin of syphilis caused the initial lesion 
to be considered as the focus of elaboration of the syphilitic germ, 
and in consequence the removal of the initial lesion was considered to 
be the most logical prophylactic treatment. All over the world excisions 
of the hard initial lesions were practiced, and we, 5 also, reported twelve 
cases of excision of hard chancres, with three successful results. On the 
other hand, many syphilologists, considering the scarcity of the results 
obtained, and moreover the doubt which naturally was arising con- 
cerning the successful cases, as to whether they were really initial 
lesions of syphilis, condemned this operation as one of no value. Zeissl, 
M. Maurice, P. A. Morrow, Corral and many others referred to cases 
of excisions of the hard chancre in which the constitutional symptoms 
of lues were not prevented. No longer than two months ago, in Ward 
C of the City Hospital, a patient was admitted with hard chancre of 
the internal surface of the prepuce, complicated with phimosis. The 
case called for circumcision. The prepuce was removed, with the 
chancre, an abundant area of normal tissue being taken out. The 
resulting wound was thoroughly disinfected with a solution of bi- 
chloride of mercury, and then the internal sheath of the prepuce was 
sewed to the external with continuous suture. The whole surface was 
healing by first intention, when seven days after the operation, in the 
left interior portion near the frenulum, the wounds of the stitches 
became ulcerated, the two surfaces detached, opened up and formed 
a new, diffused, round, hardened ulcer, replacing the first which had 
been excised. 

After these results, we have entirely given up the idea of the 
excision of the initial lesion with a prophylactic scope. Indeed, from 
our microscopical specimens we have found that the area of infection 
in the lymph spaces and in the lymphatic vessels is much more extended 
than the chancre, and the lymphatics are already infected, so that 
destroying the chancre cannot be of any advantage when an infected 
area remains around it. For this reason we prefer the application of 
the mercurial plaster, which acts so beneficially, producing the regres- 
sion of the sclerosis. It seems that the mercurial plaster attacks the 
source of the infection, so that in a few days and in an admirable 
manner it causes the healing of the chancre. 

Once in a while cases occur where the initial lesion is marked 
with chancroidal ulcers, or is associated with condylomata. In these 
cases, too, our first attention is given to the chancroids, which are 
touched with a ten per cent, solution of sulphate of copper, and then 
dressed with iodoform or aristol powder. The papillary growths or 

5 Ravogli, A. " The Excision of the Hard Chancre," the Cincinnati Lancet 
and Clinic, Nov. 12, 1883. 



THE TREATMENT OF SYPHILIS 181 

excrescences are touched with a solution of resorcin, one dram to the 
ounce of distilled water and alcohol, or formalin in the same propor- 
tions. But the speediest way is that of scraping them out by means 
of a sharp curette, and then have them touched up with liquor ferri 
perchloridi, which stops the bleeding and cauterizes the papillae, pre- 
venting their possible relapsing. 

When indurated edema and lymphangitis are present, as men- 
tioned, the use of continuous bathing of the parts with I per iooo 
solution of bichloride of mercury has been found beneficial. The 
same bathing is used in cases of thick and dense papular or pustular 
eruptions, on which it acts promptly, producing their involution and 
regression. In the hospital we place the patient in a bath tub, dis- 
solving from one to two drams of sublimate in twenty-five gallons of 
warm water. In the clinics we give to the patients bichloride tablets 
gr. vii each, to the number of from six to twelve, one tablet to be dis- 
solved in one quart of hot water for bathing in the form of wet 
compresses. 

In cases of moist papules around the female genitals, with excoria- 
tions and abundant discharge, the sitzbath with the same solution of 
sublimate is used, and when dry the mucous patches are dusted with 
calomel powder, and then covered with absorbent cotton, in order to 
prevent the contact of the two surfaces of the skin, or of the mucous 
membranes. 

When the mucous patches of the body or of the genitals are 
ulcerated or have a tendency to hypertrophy, they are touched with 
a solution of acid nitrate of mercury, three per cent., continuing the 
same treatment with bathing and calomel dressing. All moist papules 
of the oral cavity, of the tonsils and of the nose, etc., are locally 
treated in our hospital and clinics. The students touch up the patches 
with a solution of bichloride of mercury, one per cent, in alcohol and 
ether. The patient then receives a two per cent, solution of biborate 
of sodium, with a little menthol and glycerin to be used as a mouth 
wash. 

In case of obstinate dry papules on the forehead, on the palms 
or soles, the patient is directed to bathe the hand or foot or forehead 
with a soloution of bichloride for fifteen or twenty minutes, and when 
dry cover the patches for a whole night with emplastrum hydrargyri 
spread on a cloth. When the papules of the hands or soles are covered 
with thick epidermic scales, or with callosities, then the use of green 
soap is recommended to remove the scales, and after a while the em- 
plastrum is applied. For the large papules of the face or of the body 
we use a mixture of calomel and traumaticin in the following propor- 
tions : Calomel 5i, traumaticin ov. This sticks on the surface without 



182 THE MEDICAL ASPECTS 

the necessity of binding the parts. For the moist papules, which we 
sometimes find between the toes, the bathing with sublimate solution 
and the application of mercurial plaster have given us very gratifying 
results. 

In cases of diffused secondary superficial ulcerations of the lips 
or of the genitals we cover the surface with a salve containing white 
precipitate of mercury in the following formula: 

Hydrarg. praecip. alb g r . v i 

Acid, carbolic gutt. x 

Bismuth subcarb. / _ 

Zinc oxyd f aa 3 ss 

Vasilin flav 3 i 

M. f. — Unguent: apply on a cloth. 

Cases of syphilitic onychia and paronychia are treated locally with 
bathing of the hand in a sublimate solution, and then covered at bed- 
time with emplastr. hydrargyri spread on strips of lint. 

Sometimes we have to do with bad cases of syphilitic alopecia, 
which requires some local treatment. Usually a simple aromatic lotion 
to be rubbed on the scalp once a day has a beneficial effect, but when 
the alopecia assumes great proportions, then we find the applications 
of solutions of sublimate useful. We use the following mixture, to 
be rubbed on the scalp once a day: 

Hydrarg. sublimat. corr gr. xv 

Ammon. chlorid q. s. 

Aq. camphorat. \ ? .. 

Alcohol rect. J aa " 5 " 

Ad us. ext. 

In the case of gummata, emplastrum hydrargyri is the most bene- 
ficial application. When the gumma has not yet softened we apply 
the mercurial plaster spread on cloth in order to cover the gummatous 
growth and a good large area surrounding it. This produces the re- 
absorption of the infiltration so well and so easily that we have not cared 
to seek for anything better. We use the same application for syphilitic 
periostitis and for periosteal gummata, which, if not yet softened, in 
most of our cases have in a short time disappeared. 

When the gumma has undergone disintegration and suppuration 
is present, the best method is to open the cavity, scrape the internal 
surface with a sharp curette and pack the cavity with iodoform gauze. 
In cases where the ulcer has resulted from the breaking down of the 
gumma, the application of the emplastrum hydrargyri is very beneficial, 
helping to produce disintegration of the infiltrated edges and of the 
bottom of the ulcer. In the same way the sublimate bathing is our 






THE TREATMENT OF SYPHILIS 183 

best resort, when we have to do with extending gummatous ulcerations 
which have been neglected. When the sublimate bathing has cleansed 
the ulcerated surface then the mercurial plaster will be of great benefit. 
In some cases, however, the application of the mercurial plaster is 
somewhat irritant, and the application of iodoform in the form of 
salve or as a drv dressing has always given good results. 

As a local treatment of syphilis we must insist upon the cleansing 
of the mouth, throat and pharynx by means of a mouth wash and 
gargles. The use of tobacco is strictly forbidden, in order to prevent 
irritation of the mucous membranes and the relapse of moist papules. 
In the clinic and in the hospital we dispense tooth brushes and tooth 
powder to every syphilitic patient who is unable to buy, and every 
time that the patient comes to the consultation we inspect his mouth 
for the purpose of preventing salivation. 

INTERNAL TREATMENT 

All external applications will be of no avail if they are not asso- 
ciated with a strong and heroic internal treatment : a constitutional 
treatment. The most recent works on the therapeutics of syphilis have 
more and more confirmed the opinion that the only remedy against 
syphilis is mercury, and that mercury is the specific remedy against 
syphilitic processes. There was a time when the syphilologists were 
afraid to administer mercury in the tertiary forms of syphilis and the 
treatment was limited to the use of the iodides. After the works of 
Neisser mercury has become the sovereign remedy not only in the 
secondary period, but also in the tertiary stage. Iodine is a great 
adjuvant remedy. 

That the administration of mercury in the tertiary form of lues is 
a right procedure is shown by the most plausible opinion expressed by 
Neisser, Lang and Lesser, that tertiary lesions are the product of the 
immediate presence of the luetic spirilla in the tissues. The action of 
the mercury is displayed on the micro-organisms, and by its direct 
action on them the relapses are prevented. Jadassohn 6 has joined in 
the views of Neisser and their ideas have been widely accepted, that 
the tertiary lesions of syphilis, and also the papular formations of the 
secondary period are the result of the organized virus, the spirochseta. 
This opinion seems to be much more tenable than that expressed by Fin- 
ger, 7 that tertiary symptoms are the product of the toxi-albumens, the 
result of the biological productions of the micro-organisms. Finger 

6 Jadassohn, S. " Grazer Kongress d. Derm. Ges.," 1896. 

7 Finger, E. "Die Syphilis als Infectionskrankheit." Arch, fur Derm, und 
Syphilis, 1890. 



1 84 TH E MEDICAL ASPECTS 

based his views on the apparently non-infectious character of the terti- 
ary lesions. But with new observations syphilis in the tertiary stage has 
been found to maintain the same infectious nature, although on account 
of the depth of the process it is not so easily communicable as it is in 
the secondary period. With the views of Neisser and Jadassohn we 
find an easier explanation of the possibility of the coexistence of second- 
ary symptoms together with tertiary lesions, and also the transition 
from the secondary period to the tertiary. 

The quantity of the spirilla and their development are accountable 
for the greater or less severity of the symptoms, and in this regard 
there is a great deal of similarity to tuberculosis. In fact, in an 
acute miliary tuberculosis of the skin the number of the bacilli is 
large, while in a chronic form, such as in lupus, their number is scanty. 
In this way Jadassohn explains the apparently non-inoculability of 
the tertiary forms of syphilis, comparing them to the lesions of lupus 
vulgaris. To all that it is necessary to add the condition of the system 
of the infected patient and the faculty of reaction of the tissues, which 
is one of the most powerful factors in the evolution of the diseases. 

With these ideas in our minds we begin to treat our patients. 
The first question is : When do we have to begin treatment ? In our 
early years of practice we followed our old professors, and no con- 
stitutional treatment was begun unless the symptoms of secondary 
syphilis were in full blast. From this delay in the commencement of 
the treatment we can say that no bad consequences have ever followed, 
nor have we observed any more obstinacy in the disappearance of the 
symptoms. Satisfied with the results, we have continued to begin the 
treatment of syphilis at the time of the invasion of constitutional 
symptoms. 

The reply given by Fournier to this question " that it is necessary 
to begin the treatment of syphilis as soon as the presence of syphilis 
has been established," led us to commence our treatment immediately 
after the syphilitic nature of the chancre and the adenopathy had been 
found. For some years we have followed this method, with this re- 
markable observation, that in some few cases the treatment has greatly 
retarded, or has entirely prevented, the appearance of the secondary 
eruptions. This has proved that the quicker the remedy is given the 
more chances it has to show its corrective and preventive action upon 
the syphilitic diathesis. 

In these last years we have returned to the old principles, which 
is to cure syphilis constitutionally, when constitutional syphilis is 
clearly declared. As long as the patient shows a chancre he has a 
chancre, which will bring about syphilitic constitutional symptoms, but 
so far the patient has not yet syphilitic diathesis. In this regard it 



THE TREATMENT OF SYPHILIS 185 

is interesting to recall the case reported by Dubois Havenith 8 where 
a man of sixty, three weeks after exposure, showed an indurated 
chancre on the prepuce. Although it was a characteristic initial lesion, 
yet it was not followed by any adenopathy ; the chancre healed up and 
after he had watched the patient for over a year, no syphilitic symptoms 
could be found. In the discussion Barthelemy 9 and Aubert stated 
that they had met with identical cases of chancres which were not 
followed by general syphilitic symptoms. Cases of this kind are not 
rare and nearly every man interested in syphilological work has ob- 
served some cases of chancres which remained without apparent syphi- 
litic consequences. This is already a good reason for advising the 
patient to wait for the constitutional symptoms before commencing 
treatment. But the most important question for us is that while the 
patient has the chancre he has not yet syphilis. The syphilitic germs 
are working their way, they are preparing their toxins, but so far 
remain limited in the lymphatic system. In fact, we find that syphilis 
produces a decided effect on the blood, which is revealed in a form 
of leucocytosis. Stoukovenkoff, Biegaski and d'Amore established the 
fact that under the influence of the syphilitic poison there is a rapid 
decrease in the proportion of hemoglobin, as well as in the number of 
red blood corpuscles, and parallel to this an increase in the white blood 
elements, especially of the lymphocytes. 

The changes of the blood in syphilis were well studied by Ernest 
Becker, 10 in order to determine the quantity of erythrocytes and leuco- 
cytes. In two cases with roseola and general adenopathy he found a 
marked leucocytosis with predominance of the lymphocytes. The re- 
lation of the polynuclear to the lymphocytes was 65 130, representing 
in a cubic millimeter 3000 lymphocytes instead of the normal 1200 to 
1500. In patients affected with initial sclerosis without constitutional 
symptoms the blood was found in a normal condition. 

These observations have a tendency to show that the hard chancre 
is really the local focus, where the syphilitic spirochsetse are germinat- 
ing, but so far the infected person has not yet the syphilitic diathesis ; 
the toxins resulting from their germination have not yet reached the 
general circulation and for this reason the constitutional treatment will 
be of little or no benefit. 

The remark that waiting those few days we let the organism 
become impregnated with syphilitic germs has not much value. We 

8 " Comptes rendus du Congres intern, de Derm, et de Syphil. tenu a Paris 
en 1889." Paris, 1890. 

9 Quoted by Rob. W. Taylor, " Pathol, and Treat, of Ven. Diseases." Phila- 
delphia, 1895. 

10 Becker, E. " Haematologische Untersuchungen." Deutsche mcd. Woch 
enschr., 1900, pp. 35, 36. 



1 86 THE MEDICAL ASPECTS 

cannot give so large a quantity of mercury as to paralyze the develop- 
ing germs, and the remedy introduced into the general circulation will 
find no germs to fight. It is true that in a few cases we have found 
through an early treatment some delay in the appearance of the erythem- 
atous eruption, and in a few cases we did not see any eruption what- 
ever, but this we find to result injuriously for the future of the patient. 
He thinks that he has never had syphilis, or that he has had a very mild 
case, and in consequence neglects his treatment, which is the only 
safeguard against late grave affections. 

Taylor, 11 after over twenty-five years of constant study, concludes 
that the best plan is to wait until the onset of the secondary stage, 
before beginning a mercurial course. Indeed, so far, nobody has ob- 
served any real damage for the patient proceeding from the delay of 
a few days before beginning treatment. No danger is so great and 
so bad for the future of a patient as to have had a doubtful diagnosis, 
and to remain throughout his life in doubt whether or not he has 
syphilis. Furthermore, it is very bad for a patient who has never had 
syphilis to remain, on account of a wrong diagnosis, under the im- 
pression that he is suffering from syphilis. 

It is, therefore, our duty to wait for the constitutional symptoms, 
to show us that the patient is suffering with syphilitic diathesis. 

In mercury we have a remedy which directly attacks the syphilitic 
virus, but it is not a preventive for syphilis. In consequence, waiting 
a few weeks before commencing treatment does not expose the patient 
to any danger; on the contrary, it is rather better. When no constitu- 
tional symptom is present, we have no idea of the severity of the disease, 
and it is nearly impossible to institute a good rational treatment. In 
these circumstances we have seen physicians prescribe small doses of 
mercurial preparation, which has no power over syphilis, which is 
showing up with its lesions, notwithstanding the patient is taking the 
medicine regularly. This kind of mercurialization, as Taylor says, 
tends to lower vitality and impair nutrition, inducing a run-down of 
the general condition, which will tie our hands when the moment comes 
to use the proper doses of the remedy to fight severe syphilitic affec- 
tions. 

Indeed, in the primary stage of syphilis, while waiting for con- 
stitutional syphilis to begin, it will be much better to try to fortify the 
stomach and increase nutrition, thus preparing the system for the 
successive treatment. At the same time we must examine the mouth 
of the patient, have his teeth placed in good condition, so that when 
the treatment has to be given we may avoid the complication of saliva- 
tion, which prevents us from continuing the use of the drug. 

In some cases it is necessary to begin treatment before the eruption 
11 Taylor, R. W. 1. c, p. 823. 



THE TREATMENT OF SYPHILIS 187 

has shown on the skin. Quite often the general symptoms of reaction 
are so much accentuated that a quick treatment is the only relief. We 
have had patients, who, while still having the chancre in the way of 
cicatrization, with the beginning general adenopathy, have suffered 
with rheumatic pains all over the body, and with fever of a remit- 
tent character ranging between 102 to 103 F. In these cases 
specific treatment must be commenced at once, and only under this 
treatment we see the acute reactive symptoms gradually disappear. 
While under treatment, when the patient was relieved of these pains 
and the fever had entirely gone, a roseolar eruption of a deep bluish 
red color spread all over the chest, back, arms, abdomen and thighs,, 
showing the infectious nature of the disease. In cases of this kind it 
would be unwise to wait for a roseolar eruption to show the constitu- 
tional onset of the disease ; the general symptoms of pains in the joints 
and of fever were enough to testify to the general diathesis. In the 
same way in cases of a large and badly ulcerated condition of the initial 
lesion, with a tendency to spread, a well-directed constitutional treat- 
ment, although before the appearance of the general diathesic symp- 
toms, has had a good influence in checking its spreading and hastening 
its healing. 

From all that we have said it will clearly appear that in the 
ordinary cases of syphilis, before beginning treatment we prefer to 
wait for the constitutional symptoms. 

Another vital question is how to administer this treatment, con- 
stantly or intermittently, and how long it ought to be continued. In 
this regard there are two principal opinions : one, which is followed by 
Caspary, Kaposi, Pick, is the so-called symptomatic treatment, because 
when the symptoms disappear treatment is stopped ; the other, which 
has been established by Fournier, continues the treatment whether the 
symptoms are present or not in a continuous intermittent way. Neisser 
has accepted the ideas of Fournier, and with very few exceptions he 
has introduced the method of treatment into Germany. They start 
with the belief that syphilis is a chronic disease, and must therefore 
receive a chronic treatment. Mercury causes surely and quickly the 
regression of the syphilitic symptoms, and it is also capable of prevent- 
ing or delaying consequent relapses. For this reason mercury is the 
true and reliable remedy, which must be used in a chronic manner in 
this disease. 

It is necessary to keep in mind the fact that the organism gets 
used to the drugs, and the drug loses its therapeutic efficacy on account 
of the continuous administration ; for this reason it is better to make 
some intervals in the treatment, or, as Fournier says, treat the disease 
with a chronic intermittent treatment. 



1 88 THE MEDICAL ASPECTS 

In fact, we have no clinical nor physical signs by which we can 
be sure that the virus is entirely out of the system. By clinical expe- 
rience we know that syphilis can break out again suddenly and entirely 
unexpectedly. Moreover, we all have observed cases of individuals 
who have been considered perfectly cured for years, yet who have 
shown signs of hereditary syphilis in their children. 

In order to avoid these consequences, we agree with Fournier and 
Neisser, that the treatment must be chronic and intermittent so as to 
free the organism of the syphilitic virus, and prevent in this way other 
relapses. Nobody can foresee the severe consequences which may 
come from a case of syphilis, nobody can state that syphilis has been 
perfectly cured, or is still latent in the system, and consequently, re- 
gardless of the mildness of the symptoms, every case of syphilis must 
be treated for years with mercurial preparations. 

In regard to the methods of administration of mercury, we find 
ourselves in the necessity of using the different ways of application 
according to the conditions of the patient, the place where we treat the 
patient and the nature of the syphilitic symptoms. We have always 
found ourselves unable to say that we treat the disease only by internal 
administration of the remedy, or only by inunctions, or intramuscular 
injections. Every method is good ; but every one has its disadvantages, 
and for this reason it is better to change accordingly. 

In the clinic, a patient who has come with a hard chancre receives 
an emplastrum hydrargyri, which he uses on .a piece of muslin to cover 
the lesion, and is directed to apply two other pieces on both groins for 
the affected glands. He receives for internal medication only a mixture 
of iron, quinia and strychnia as a tonic, if his general nutrition was 
somewhat faulty. We direct the patient to come to the consultation 
once a week, and when we find erythema of the pharyngeal ring, and 
spots of roseola begin to appear, we prescribe a solution of I per iooo 
of bichloride of mercury, which has the name of Liquor VanSwieten. 
The formula is : 

Hydrarg. bichlorid. corros gmm. 0.90 

Alcohol 9 6 -°° 

Aq. Destillat 928.00 

This solution contains exactly 1 to 1000 of sublimate in weight, which 
is two and one-half centigrammes for each 32 grammes ; in consequence 
a tablespoonful contains exactly 1 centigramme and one-fourth. 

The patient takes one tablespoonful of this solution twice a day, 
one immediately after his breakfast and one after his supper, diluted 
in one gobletful of water. This gives to the patient half a grain of 
sublimate per day. In our hands, as well as in the hands of other 






THE TREATMENT OF SYPHILIS 189 

practitioners, this solution has given excellent results. We do not like 
the sublimate in pillular form on account of the uncertainty of the 
complete dissolution of the pill in the stomach, and furthermore on 
account of the possibility of some injurious action of the pill, which 
dissolving in one limited part may harm the mucous membrane of the 
digestive tract. For these reasons we find that the remedies in pillular 
form are rather unreliable, and this recalls the great therapeutic axiom, 
Corpora non agunt nisi sohita. 

With that tablespoonful of 1 per 1000 of bichloride diluted in 
water, we get a beneficial local action on the mucous membrane of the 
pharyngeal ring, and a solution of mercurial salt which is easily ab- 
sorbed by the stomach. In several hundred patients of both sexes 
coming to our clinic yearly, we have never found one who has com- 
plained of cramps or of other gastric troubles in consequence of this 
medication. It is very convenient, especially for working people, to 
take this medicine with their principal meals and not to have to think 
any more about taking medicine during the day. In private practice, 
especially among women, we advise the same doses, only more frac- 
tioned, for instance four dessertspoonfuls a day of the sublimate 
solution diluted in Vichy water, as recommended by Brocq. 12 Very 
seldom has it happened that we have found anyone who has any 
repugnance for this remedy so administered, and in those few cases 
after a short time they could take the medicine without any trouble. 

INJECTION TREATMENT 

Under this medication the patient begins to feel much better, 
much more cheerful, but the eruption shows plainly. Then we begin 
the treatment with the injections with gray oil, according to the formula 
of Lang: 

Metallic mercury 30 is in- 
corporated by stirring in a mortar with a mixture of Lan- 
olin anhydric 15 

Cholorof orm 50 

When the chloroform has been entirely evaporated, the lanolin with 
the mercury has formed the unguentum lanolinatum forte. This is 
then mixed with oleum vasilini in the following proportions : 

Unguent, lanol. fort 9 

Ol. Vasilini 3 

This is the gray oil, which must be warmed each time before using 
in order to have it fluid and ready. In place of the oleum vasilini, we 

12 Brocq, L, " Les doses fractionnees de bichlornre et de bijodure de 
Mercure," etc. Festschrift f. M. Kaposi, 1900. 



190 THE MEDICAL ASPECTS 

have substituted the fluid albolin, which maintains the oil at such a 
consistency that it can be injected without warming the mixture every 
time it is to be used. 

In private practice, clinical and hospital, before making the injec- 
tion we dip the needle and part of the Pravaz syringe in boiling water. 
The nurse rubs the skin in the anatomical region chosen for the injec- 
tion (the gluteal region) with a tampon of cotton saturated in alcohol, 
and then the injection is made by thrusting in the needle with one 
quick blow in a horizontal direction deep into the muscular masses. 
The needle is one of the ordinary size and length. The ring around 
the piston of the syringe is set to give as many drops of gray oil as 
we intend to inject. Three rings of the screw gives five drops of the 
gray oil. We begin with five minims, which according to the symptoms 
we raise to ten and twelve. The gluteal region of the right side is 
used for the first injection, the left for the second, so that all the odd 
numbers are on the right side, and it makes it easy to remember the 
number of the injection. In the beginning of the treatment we give 
two injections per week, but after two weeks, that is after four 
injections, one injection per week is sufficient, which we make with 
eight minims of the oil. 

It is necessary to recommend to the patient to remain with the 
muscles entirely loose at the moment of inserting the needle, and not to 
jerk or contract the muscles, as a sudden contraction might be danger- 
ous and break the needle, or at least make the injection painful. When 
the injection is well given, no pain follows, but the following day the 
patient feels a kind of numbness, and the place where the gray oil has 
been injected is found to be somewhat hard, but in a few days this 
disappears entirely. It is entirely the opposite with the injections of 
corrosive sublimate, which we have used for so many years, also with 
good results. We have injected the old I per cent, solution, as used 
by our friend and teacher, Heinrich Auspitz, deep under the muscular 
masses, but the patient is immediately affected with an acute pain in the 
place of the injection, which lasts for several hours. For the same 
reason we have given up the injections of cacodylate of mercury, ac- 
cording to the formula of Brocq, on account of the unbearable pain 
which had constantly followed the injection. 

As a consequence of the injections with the gray oil, notwithstand- 
ing the best care for asepsis, once in a while it happens that some 
patient has an abscess. The place where the injection was made be- 
comes hard, swollen, red, and pains, and in a few days fluctuation is 
found. We are in the habit of opening the abscess as soon as the 
fluctuation is perceptible. There comes out a quantity of thick, bloody 
serum, containing shreds of necrotized connective tissue, together with 



THE TREATMENT OF SYPHILIS 191 

minute granules of metallic mercury. It is difficult to explain the 
reason of the abscess, when we consider that for every injection we 
use the same precautions of asepsis. The abscess is much more liable 
to come in women than in men, so that while we have not had an 
abscess in private practice or in the clinic, in the female ward of the 
hospital several abscesses have occurred following the injections with 
gray oil. 

The abscess is not painful, as a rule, and fortunately it heals 
readily, but in one case the abscess was deeply seated between the mus- 
cular masses. Although the abscess is an inconvenient complication, 
yet it is not of such importance as to diminish the value of this method 
of treatment. 

In our hospital ward we have used the intravenous injections 
with 0.1 per cent, sublimate solution, as it was introduced in 1893 by 
our clinical professor, Guido Baccelli, of Rome, and then practiced by 
Jenuna, Colombini and Campana in Italy, by Goerl Newnan and Lewin 
in Germany, and by Ernest Lane in England. The injection has been 
done following his technique. The flexion surface of the elbow is 
selected for the injection. The surface must be perfectly sterilized; a 
bandage is tied around the arm just above the elbow in the same way 
as it was used for bleeding. The vein then swells up, filled with blood. 
With the two fingers of the left hand the vein is held, and with the 
right hand the needle of the syringe is inserted into the vein. By push- 
ing out a drop of the solution, which if not appearing under the skin, 
we are sure that the needle is in the lumen of the vein, then an assistant 
removes the bandage, so as to take off the pressure, and the fluid is 
gently and gradually injected into the vein. The needle is removed, 
and a piece of gauze is placed on the wound and this is bandaged. The 
syringe full contains one c.c. of solution 0.1 per cent., which represents 
1-64 of a grain of corrosive sublimate. The dose has been increased 
by using a 0.2 per cent, solution, and Blaschko has increased the dose 
to the amount of 0.6 per cent. 

A great deal has been claimed for this method, by which the mer- 
cury is introduced directly into the blood and taken by the shortest way 
to the diseased places. The presence of mercury in the system, al- 
though introduced in such a small amount, is felt by the patient, who 
has a metallic taste in his mouth, and Baccelli claims to have seen 
patients become salivated five or six minutes after the injection. One 
hour after the injection the presence of mercury could be demonstrated 
in the urine, and it disappears the following day. But when the injec- 
tions are continued daily, the presence of mercury can be found in the 
urine one or two weeks after the last injection, as stated by Blaschko. 
Moreover, there is no doubt that in the florid stage of syphilis, either 



1 9 2 THE MEDICAL ASPECTS 

spirochsetse or toxins are to be found in the blood, and introducing the 
mercurial preparation directly into the blood will attack and destroy the 
syphilitic virus. In cases of syphilitic arteritis, and much more in the 
cases of cerebral syphilis, it seems to be the ideal method of medication 
to bring the remedy directly into contact with the intima of the dis- 
eased vessels, or with the vessels surrounding the nervous cells. 

Tommasoli, 13 in a recent article, considers this method the abortive 
treatment of syphilis. He claims that a certain number of intravenous 
injections from 6 to 8, and from io to 20 milligrammes each, given in 
the beginning of the constitutional symptoms, will kill the disease. 
Tommasoli is so well pleased with the method that he would compel 
every physician to use this method in the beginning of every case of 
syphilis. 

Ernest Lane in a paper which he read before the International 
Congress of .Dermatology in London, said that he had adopted this 
method of intravenous injections in the treatment of syphilis in every 
case which had come under his care, for the period of nine months. 
The greatest advantage which he could find was the rapidity with which 
the patients could be brought under the influence of mercury. 

We had occasion to see some cases selected by him in which the 
symptoms had greatly improved under a constant treatment of 45 in- 
jections into the veins, with a solution of 1 per cent, of cyanide of mer- 
cury. The results, when compared with the method of gray oil 
injections between the muscular masses, or even subcutaneously, do not 
show any improvement over it. The same results which we obtain 
with four or six injections, made at the intervals of one week one from 
the other, were obtained with forty intravenous injections practiced 
every day. We are sure that this is already a good ground for dis- 
carding this method. In our C ward we selected six cases of papular 
and papulo-pustular syphilides, which we began to treat with intraven- 
ous injections of 0.2 per cent, solution of sublimate. We were com- 
pelled to desist from our experiments because the patients refused to 
have any more injection, complaining of unbearable pain from the point 
of their injection, radiating towards the shoulder. We cannot say that 
the injections caused any thrombotic deposits in the vein, as was the 
case with M. Dinkier, in which a total obliteration of the lumen of the 
vein took place, but we will always insist that with the ordinary sub- 
cutaneous injections we are able to obtain good results in an easier way. 

In cases where we wish to obtain a rapid mercurialization, espe- 
cially in the hospital wards, on account of threatening syphilitic nervous 
symptoms, or in cases of 'iritis, iridocyclitis, then we resort to the injec- 
tions with calomel, which in our opinion acts much more quickly and 

13 Tommasoli, P. Ann. de Derm, et de Syph., Dec, 1902. No. 12, p. 1073. 



THE TREATMENT OF SYPHILIS 193 

much more powerfully than any other remedy. Calomel by subcuta- 
neous injections was the first remedy which opened a new era in the 
treatment of syphilis. We must be grateful to the genius of Scarenzio, 
who was the first to inject calomel and to show the wonderful results, 
which have entirely revolutionized the old disagreeable methods of 
treatment. For a few years in the early days of our practice we applied 
subcutaneous injections with calomel, which we did by mixing five 
grains of it with water and mucilage. The injection was made in the 
external region of the arms or on the external region of the thighs into 
the subcutaneous tissue. The results were absolutely remarkable, but 
after nearly every injection an abscess followed, which made the 
method rather objectionable. Furthermore, after one injection severe 
cases of stomatitis followed, which compelled the discontinuance of 
the treatment. 

It was for this reason that w r e readily accepted the method of 
Lewin, used so extensively by Auspitz, which consisted in the injec- 
tion of a solution of 1 per cent, sublimate under the muscular masses. 
Although the injection of sublimate did not act so promptly as the 
calomel, and although its action was not continuous like that of the 
calomel, it being necessary to repeat the injection too often, yet it was 
preferable to the calomel on account of avoiding the abscess and the 
salivation. Here we enter into the important question of the soluble 
salts of mercury, or of the insoluble salts. The bichloride was the first 
soluble salt to be injected, and still maintains its reputation. Next 
came the cyanide, the peptonate, the benzoate, the cacodylate, which, 
displaying less power and not an equal therapeutic action, have been 
abandoned. For some time there has been used by Wolff, of Stras- 
bourg, and by Jullien the succinimide of mercury, which has given in 
their hands satisfactory results. The soluble salicylate of mercury, and 
also the biiodide of mercury in oily or in aqueous solutions, have been 
used with good results, but certainly not superior to those obtained by 
the use of the sublimate. 

The massive injections of sublimate in serum have been praised 
greatly by Cheron, but the experience of Jullien 14 is sufficient to place 
this method entirely under ban as dangerous and injurious. 

With the insoluble salts the action of the remedy is entirely dif- 
ferent. The remedy is placed in the tissues, and there it finds the 
appropriate ingredients for being transformed into a soluble prepara- 
tion, and is thus gradually absorbed, producing a soluble and a per- 
manent therapeutic action. These studies have been made by Scar- 
enzio, who, together with Smirnoff and Soffiantini, have tried doses of 

14 Jullien, L. "A propos des injection mercurielles." Journal dcs Maladies 
eutanees et syphilitiques, 1902. 



194 THE MEDICAL ASPECTS 

calomel from the smallest to the largest, have studied the local action 
and the general systemic action with such accuracy that not much 
remains to be added. 

Under the injections with calomel, the rapidity of absorption is 
indeed remarkable. By repeated analysis, Nicolich 15 demonstrated 
the presence of mercury in the urine from two to three hours, and 
in the saliva from four to five hours after the injection. Jullien showed 
its presence in the milk a few hours after the injection with calomel. 
We will use the wise and expressive idea of Jullien, that the injection 
of calomel is like a small chemical laboratory, which produces a soluble 
mercurial preparation gradually, and constantly until the supply of raw 
material is exhausted. This is not a simple opinion, but it has been 
proved by chemical analysis by Vigier, Frolow and Girard, who several 
months after an injection with calomel, in the resulting indurated focus, 
were able to demonstrate the presence of mercury. It is undeniable 
that when the insoluble mercurial preparation is injected in the sub- 
cutaneous tissues, or better, between the muscular masses, an inflamma- 
tory process takes place, which produces and organizes a membrane, 
as in the abscesses, the pyogenic membrane which encapsulates and 
surrounds the injected remedy. By means of asepsis, true suppuration 
cannot occur, but there is displayed the action of the leucocytes against 
the remedy which acts as the intruder. 

Picardi 16 made some interesting experiments in the laboratory of 
professor Bizozero, to demonstrate the absorption of calomel in the peri- 
toneal cavity, showing that it depended not only on the fluids, but also 
on the elements of the tissues. The granules of calomel act like any 
other indifferent substance ; they cause an immigration of leucocytes, 
which surround and take them into their body, and so they are trans- 
ported into the lymphatic glands. The leucocytes show a phagocytic 
power with regard to the calomel and a positive chemiotaxis. This, 
however, cannot last long and some calomel always remains, contrary 
to what happens with other indifferent powders. This is explained by 
Picardi by the fact that, when the calomel begins to be changed into 
sublimate, the leucocytes in the immediate vicinity are poisoned and 
are unable to continue their work of opposition. Picardi, however, 
experimented on the peritoneum, where the absorption is so very active, 
while we make our injection in the connective tissues of the muscular 
masses. Here the activity of the circulation is less, and according to 
Jullien, the leucocytes appear somewhat later, when bichloride has al- 

15 Nicolich. " La cura della sifilide col metodo del Prof. Scarenzio," Trieste, 
1898. 

16 Picardi. " Sul riassorbimento delle injezioni di calomelano." Policlinico, 
Rome, 1896, No. 18. 



THE TREATMENT OF SYPHILIS 195 

ready been formed, and in consequence they cannot approach and dis- 
play their phagocytic power, and therefore the quantity of calomel is 
left there to undergo the gradual chemical transformation. For this 
reason particles of calomel are not found in the lymphatic glands after 
the injection, but it reaches them rather in the form of bichloride, pro- 
ducing a mild swelling. 

With the rules of asepsis, to-day the so much lamented abscesses 
in consequence of the injections w T ith calomel have been rendered not 
so frequent. We have returned to its use, diminishing the dose, which 
was formerly too high. Scarenzio himself, later on, used the highest 
dose of 10 centigrammes, which is 2 grains. In our clinic we never 
exceed the dose of 1 grain or 5 centigrammes of calomel for the first 
injection, and one-half grain for the successive injections, which we 
repeat once a week, or once every two weeks, according to the 
symptoms. From the results which we have obtained, we can agree 
with the conclusions given by Fournier : that the treatment of syphilis 
with the injections -of calomel is active and powerful; that the results 
obtained are very good ; and that in some cases these results are won- 
derful, displaying an extraordinary therapeutic intensity. 

One drawback to the injections with calomel is the salivation, 
which has started in some cases a few days after the first injection, and 
which has sometimes lasted for a long time after ceasing the use of 
every mercurial preparation. For this reason we reserve the Scar- 
enzio treatment for those cases which require a rapid and intense 
action. In obstinate cases of miliary papular syphilide, in cases of 
glossitis, laryngitis, iritis, of ulcerated gummata, etc., the injection with 
calomel has always given splendid results. Moreover, in the cases of 
syphilis affecting the nervous centers, where a powerful and speedy 
action is necessary, the injection with calomel will give the most satis- 
factory results. 

For the ordinary cases of syphilis which come every day to the 
clinic, to the hospital and to private practice, we prefer our routine 
treatment, such as we have already described. 

INUNCTIONS 

In the beginning we stated that we are not exclusivists in the treat- 
ment of syphilis, and that we apply every method of introducing mer- 
cury into the organism of the patient that will effect his cure. Even the 
oldest method of introducing mercury through the skin by rubbing is 
not laid aside. This method was of the greatest service in the fifteenth 
century, in checking the ravages of the new epidemic, as it was called, 
or the Neapolitan or French disease. The inunctions with mercurial 



196 THE MEDICAL ASPECTS 

salve have been looked upon as a godsend for humanity. Unfortu- 
nately, the method was so badly applied, the administration being made 
without rules and in an excessive quantity, so that from its abuse all 
kinds of injurious accidents occurred, especially stomatitis, which 
caused not only fear, but a horror of mercury. At that time it was 
believed that salivation was a beneficial effect obtained by the remedy, 
which was driving the syphilitic poison out of the system through 
that flow of saliva. As a consequence, every patient in order to be 
cured of syphilis had to be salivated, and when the saliva w r as flowing 
out of his mouth, when there was present in the mouth that unbearable 
odor, that was the moment for rejoicing, because the bad humors were 
leaving the system and the cure was progressing. 

To-day we know that salivation is only a complication, or better, 
a disagreeable occurrence, which we can avoid to a certain extent. 
Salivation compels us to subside treatment and lose time which could 
be of great value for the health and for the future of our patient. 

To-day we have entirely abandoned the administration of all de- 
purative beverages and decoctions, which were given during the inunc- 
tion treatment, after having recognized that they are not only useless, 
but injurious to the stomach and to the general nutrition of the patient. 
Neither do we take any interest in keeping our patient confined, nor in 
subjecting him to a vapor bath before using the inunction. 

We usually treat our syphilitic patients by means of the inunc- 
tions in the hospital wards. In private practice, most of the patients 
find the inunction treatment objectionable on account of its soiling their 
clothes, and arousing suspicion amongst others. In the same way they 
find it objectionable on account of the loss of time when tired out 
after a day's work ; they must rub themselves for twenty-five or thirty 
minutes going to bed. In our clinics, too, the inunctions cannot be 
applied, and the patients ask for some other method of treatment rather 
than take them. 

In the hospital wards, however, the patient has nothing to do, 
and finds it pleasant to spend half an hour rubbing. In the use of in- 
unctions, hairy parts must be avoided as much as possible. When the 
mercurial ointment is rubbed on regions having many hairs, it often 
irritates the follicles and causes a form of dermatitis and folliculitis. 

For rubbing, we use the ordinary unguentum cinereum, which 
is made of mercury incorporated with lard, of equal parts. To-day, 
however, the mercurial ointment prepared with vasogene, containing 
thirty-three per cent, of mercury, is better applied. Vasogene, accord- 
ing to the studies of Goldmann, 17 Ullmann, and others, is much more 

17 Goldman, J. A. " Die therapeutische Verwendung des Teer Vasogen." 
Monatshefte fur pract. Derm., IQ02, B. 34. 



THE TREATMENT OF SYPHILIS 197 

easily absorbed than an ordinary mercurial salve prepared with lard. 
We can agree with the conclusions of the authors mentioned, 18 because 
since we have introduced the vasogen mercurial salve we have found 
more active action and not so frequently do we meet with signs of irri- 
tation of the skin, dermatitis and folliculitis, which have often followed 
the inunctions with the ordinary Neapolitan ointment. 

It is interesting to know how the mercury is introduced into the 
system by means of the inunctions. In general, we can state that mer- 
cury is introduced in the skin mechanically in the same chemical and 
physical condition as it is in the gray ointment. It is, however, not 
impossible that the finely divided mercury mixed with the vehicle may 
find on the skin or in its pores materials with which it can make com- 
binations and be absorbed in this way. We must also keep in mind 
that mercury volatilizes on the surface of the skin, and it is also 
absorbed in the form of mercurial vapors. In this case, however, the 
lungs will take part in the introduction of mercury by inhalation, and 
by the absorption occurring on their surface. Kirchgauer has pub- 
lished some of his ideas on the action of the mercurial vapors in the 
inunctions, and Remond, Menget, Welander and Neisser have had so 
much faith in their action as to establish a method of treatment by 
linen sacks filled with mercurial ointment. 

We must confess that we are somewhat skeptical on this subject, 
and we rather believe in the mechanical introduction of the compressed 
mercury, finely divided, into the pores and follicles of the skin. There 
is no doubt that mercury, which so easily vaporizes, must impregnate 
the atmosphere with mercurial vapor, arising from the rubbing of the 
ointment, which is inhaled by the patient. We do not believe, however, 
that it goes far from the patient, for the reason that if this atmosphere 
penetrated far, our nurses in wards C and O would be constantly 
salivated. 

From the microscopical examinations made by Juliusberg 19 on 
pieces of skin removed soon after the inunction, it results that no mer- 
curial globules are found under the epidermis or in the tissues of the 
corion, but they are found in the follicles of the hair and in the open- 
ings of the sebaceous and of the sweat glands. Filhene 20 was also of 
the opinion that the epidermis does not allow the passing of mercury 
through its cells, but that the absorption is made through the sweat 
glands, sebaceous glands and hair follicles. 

18 Goldmann, J. A. " Erfahrungen iiber den therapeutischen Effect der 
Qnecksilber Vasogen salve," same, B. 35. 

19 Juliusberg, F. " Experimentelle Untersuchungen iiber die Qnecksilber 
Resorption bei der Schmier Kur." Arch. f. Derm. u. Syph., 1901. B. lvi, Heft 1. 

20 Filhene. "Ueber die Durchgangikeit der menschlichen Haut fur teste 
und fliissige Stoffe." Berlin klin, Wochensch., 1898. 



198 THE MEDICAL ASPECTS 

In regard to the way in which mercury is absorbed through the 
skin by means of the inunctions, it seems that it is taken up in the 
form of small metallic globules by the leucocytes, and in this way 
carried in the lymph vessels and in the general circulation. This was 
the idea of Auspitz, 21 which was followed by Oesterlen, Eberhard, 
Overbeck, Blomberg, who claimed to have found small globules of 
metallic mercury in the corium and in the subcutaneous tissue after the 
inunction with mercurial ointment. Many others, on the contrary, 
have denied the presence of metallic globules in the tissues of the skin 
after the inunction, and they believe, therefore, that mercury musr 
undergo some chemical changes and is absorbed in a different combina- 
tion, which cannot be seen under the microscope. Baerensprung 22 be- 
lieved that the efficacy of the gray salve was due entirely to the oxydul 
of mercury, which is formed by combination with the fat, and in this 
way is absorbed. The presence of this oxydul of mercury in a recently 
prepared salve has-been found through the researches of Wings and 
Anuschat to be so insignificant that it cannot surely be the cause of its 
absorption. Mealhe, Voit and Fiirbringer have found no necessity of 
any presence of oxydul of mercury in the unguentum cinereum, but 
they believe that the oxydation of the mercury takes place just exactly 
where it is rubbed, and this mercurial oxide with the secretion of the 
skin makes a soluble preparation, which is easily absorbed by the skin 
and introduced into the circulation. This, however, is nothing more 
than a hypothesis, and as to the soluble mercurial salts made with the 
secretions of the skin, so far nobody has been able to demonstrate their 
existence. 

At any rate it would be necessary to establish not only the manner 
in which mercury enters the system by means of the. inunctions, but also 
the quantity which is introduced. We are unable to say anything posi- 
tive as to whether the mercury is absorbed from the tissues, or from the 
leucocytes as small globules, or is changed into a soluble chemical prod- 
uct, easily absorbable into the system. Nor are the experimenters 
named able to state whether a large quantity of mercury vaporized dur- 
ing the inunction is taken in by the pulmonary epithelium, because no 
mercurial globules have ever been demonstrated in this epithelium. 

On the other hand, they have all demonstrated the presence of mer- 
cury in the urine some time after the inunction. The quantity of 
mercury in the urine was much more abundant when the inunction was 
made in the ordinary way, and much less when it was made under a 

21 Auspitz, H. " Ueber die Resorption ungeloster Stoffe durch die Epi- 
dermis." Arch. f. Derm, und Syphilis, 1871. 

22 Baerensprung. " Ueber die Wirkungweise der Quecksilber praparate und 
ihre Anwendung bei Syphilitischen." Ann. der Charite, 1856. 



THE TREATMENT OF SYPHILIS 



199 



cover of impervious cloth. This would seem to speak in favor of some 
absorption through the lungs of mercurial vapor produced by the 
action of rubbing the mercurial ointment. 

We know, however, by experience, that mercury is introduced into 
the system by means of inunctions, and the frequent cases of salivation 
following this method are a sure proof of its absorption. We are, 
however, not very much in favor of this method as a general and 
ordinary treatment, but we use it mostly in special cases. In tertiary 
syphilis, when a mixed treatment is required, in individuals already 
emaciated and cachectic, we prefer to subject these patients to the in- 
unctions. In the same way in the female department, all the syphilitic 
patients who refuse the mercurial injections are treated with the inunc- 
tions. At the end of the syphilitic treatment before discharging the 
patient we often advise him to take a course of twelve inunctions. We 
reserve this method of mercurial ointment inunctions rather for the 
hospital and for private practice, and have abandoned it in the clinics. 
The quantity of ointment to be rubbed is from 1 to i-| drams, and the 
inunction is made every other day. Only in cases where a quicker 
action is required do we direct the patient to anoint every day. The 
time employed for rubbing is from fifteen to twenty-five minutes. The 
patient himself makes his inunctions, and the nurse, with the hands 
protected by gloves, gives the inunctions only in cases of paralytic 
patients, or in children affected with congenital syphilis. 

The regions which are chosen for rubbing are the same as those 
used by Professor Sigmund. 

First, the hollows of the feet. 

Second, the internal regions of both legs. 

Third, the internal regions of both thighs. 

Fourth, both sides of the chest. 

Fifth, the internal surface of both arms. 

Sixth, the flexion surface of both forearms. 

The quantity of the salve, 3 i to 3 iss, is divided into two parts 
for both sides of the body. The patient must rub hard, with the palm 
of his hand, until the salve is nearly dry. We caution our patients not 
to wash the skin soon after the inunction, in order to avoid dermatitis, 
and to cover the surface with a flannel bandage. In this way the 
salve remains in contact with the skin for several hours. On the fol- 
lowing day the place rubbed is washed with soap and warm water, and 
when dry is dusted with rice powder. 

The inunctions can be continued for two weeks, rubbing every dav, 
and for four weeks, rubbing every other day. It is necessary to 
examine the mouth of the patient every day, and when signs of saliva- 
tion appear, to cease their use immediately. 



200 THE MEDICAL ASPECTS 

Although by this method we have obtained and do obtain good re- 
sults, yet it has many inconveniences which make it distasteful and 
disagreeable to the patients, and doubtful and unreliable for the physi- 
cian. Our patients, especially in private practice, object to this method 
on account of soiling their clothing, and for this reason they seriously 
ask whether there is not some other method of treatment. The soiled 
clothes may expose their secret and make known to everybody that 
they are under specific treatment. Furthermore, it quite often pro- 
duces eruptions in the form of folliculitis, or of erythema, or of mer- 
curial eczema, which compels us to discontinue the use of the 
inunctions. 

For the physician this method is doubtful and unreliable for the 
simple reason that we know that the patient rubs one dram of mer- 
curial ointment, but we do not know how much of it is absorbed. 
We do not know how long the patient rubs the salve in, and with 
what strength he anoints. Sometimes, after many inunctions, we do 
not see any noticeable results, and all at once we find our patient 
badly salivated. Consequently we use the mercurial inunctions mostly 
in the hospital, where they are carried out with exactness, under the 
surveillance of the nurse, and the patients are not afraid that the soiled 
clothing may reveal their trouble. 

We also use the inunctions as above mentioned in our private 
practice at the end of the treatment, and the patient is advised to go 
if possible to some thermal place where the inunctions can be carried 
out without so many inconveniences, with the beneficial aid of the 
thermal bath. 

We must again see our patient in the clinic, to whom we have 
given twelve injections of from 5 to 10 mms. each of gray oil, at 
intervals of one week. In the ordinary cases we find that the syphi- 
litic symptoms have nearly entirely subsided, or that very little remains 
of them. The improvement showing the beneficial action of the 
remedies on luetic symptoms, and on the other hand some loss of 
weight of the patient, prompts us to abandon for a while the use of 
mercury while we continue the use of iron tonics. 

After the patient has remained three weeks without mercurial 
treatment, we begin again the use of the solution of bichloride, or if 
it is more convenient we give the pills of protoiodide. Judging from 
our experience we have slight objection to the protoiodide pills, which 
we use in a dose of £ grain each. We prefer the protoiodide at the 
time when syphilis begins to show papules, when there is already a 
tendency to infiltration. We find that the protoiodide still maintains 
its reputation, which it had so widely gained at the time of Ricord, 
under the name of pills of Ricord. We give in our clinic usually 



THE TREATMENT OF SYPHILIS 2 OI 

thirty pills of J grain each, and we direct our patients to begin to 
take them, one after each meal for three days, and then every three 
days increase one pill until he reaches the dose of two pills after each 
meal. When the patient takes six pills a day we direct him to continue 
the dose for three weeks and then discontinue. The six pills give gr. 
1^ of protoiodide, which is considered a sufficient dose, especially after 
the patient has undergone other treatments, and there are no symptoms 
urging a stronger mercurialization. 

Although the protoiodide is considered to be an irritant for the 
mouth, often producing salivation, yet in our practice we have but 
rarely seen cases of stomatitis from the use of the protoiodide. In 
one case we had very severe stomatitis with some gangrenous patches 
of the gums and of the mucous membrane of the mouth, associated 
with a grave dysentery. It was a patient who had attempted to treat 
himself, without medical direction, and for nearly four months con- 
tinued the use of the protoiodide pills, taking at a dose from eight to 
ten pills per day, without intermission. With this exception we have 
found that in most of the cases the protoiodide is well tolerated, and 
constitutes a convenient and good remedy. The patient buys a small 
vial containing 100 pills and after each meal takes one, two or three, 
according to the direction. The pills contain the same ingredients as 
the formula of Ricord, except that they contain J of a grain of 
protoiodide. 



Hydrarg. Protoiodid gr. 25 

Extr. Op. Theb gr. 15 

Thridac gr. 25 

Conserv. Rosae q. s. 

This makes a pill, pasta to be divided into 100 pills. 

During the treatment with protoiodide pills we advise our patients 
to take them intermittently, leaving from two to three weeks' interval 
in order to rest the stomach and much more the intestines. In fact, 
the sublimate soon shows its irritant action on the stomach, while the 
protoiodide shows it in the intestines, provoking temporary attacks of 
diarrhea and of dysentery. For this reason the pills always contain 
a small dose of opium to counteract the intestinal irritation. 

The patient continues his treatment with the pills in the way we 
have described for five or six months, and after this period he takes 
another course of treatment with gray oil injections, or with inunc- 
tious of mercurial ointment. The injections are given one per week, 
and if no persistent symptoms are present, eight or ten injections are 
sufficient. 

The treatment must be regulated according to the symptoms. In 



202 THE MEDICAL ASPECTS 

some cases there are no symptoms present, and a few injections will 
be sufficient for the second course of treatment, but when the patient 
has ulcerated papules of the throat, relapsing papular eruptions on 
the body or on the scalp, the treatment must be kept up constantly. 

FUMIGATION 

Mercury succeeds in curing any case of syphilis, but, as I said 
above, it is necessary to know how to handle it and how to ad- 
minister it in the different cases. In very grave syphilitic cases, 
when we have had no results from the inunctions, or from other 
methods, we have resorted to the mercurial fumigations. It is an old 
method, which was considered a great deal in the first epochs of the 
treatment of syphilis, for the reason that it quickly brought about 
salivation, but it has been recently nearly abandoned. We use the 
method of fumigations only in special cases, like those of an extensive 
ulcerative process, or large multiple gummata with a cachectic general 
condition, in cases of syphilis of the internal organs and also of the 
nervous system, when other methods have failed. In our hospital 
wards we have a wooden cabinet where the patient sits with his head 
out. Under the chair is placed an apparatus for producing vapor. 
It consists of a japanned tin box, with a movable lid, hollowed out 
like a saucer with a pedestal and a small alcohol lamp. In the little 
cup in the middle there are placed fifteen grains of calomel, and the 
hollowed lid is filled with water. The lighted alcohol lamp is put 
inside of the box and the whole apparatus is placed under the stool. 
Vapors of sublimated mercury are given off and surround the patient. 
We leave the patient in for fifteen minutes ; after this time the skin is 
found covered with drops of water. In private houses having no 
cabinet we can substitute a blanket, which is tied around the head, 
leaving the face free, and covering the patient as he sits on a chair. 
After the bath the patient must be put to bed and the perspiration 
kept up. There are no unpleasant sensations and it can be applied 
every other day without discomfort. 

Lalouette 23 claimed for this method certainty and convenience, 
and he stated that with twenty or twenty-five fumigations any case 
of syphilis could be cured. It has been favored by Langston Parker, 
Henry Lee, Bumstead, Duncan, Wilders, Horteloup and others, all 
claiming quick and sure therapeutic results. 

We have used this method with satisfactory results in only a few 
selected cases, when other methods had failed. When the patient 
improved we have given him treatment with other ordinary methods. 
The treatment with fumigations causes stomatitis much sooner than 

23 Quoted by Fournier. 



THE TREATMENT OF SYPHILIS 203 

other methods, and we find it uncertain on account of our being unable 
to calculate the power of absorption of the skin and also of the 
respiratory organs for the vaporized remedy. 

After reviewing all the different methods of treatment, we come to 
the conclusion that we cannot limit ourselves exclusively to any method 
of treatment; we must use every one according to the exigencies and 
conditions of the case. But we must say that for a routine treatment 
in ordinary cases in private practice and in clinics, the injections 
with gray oil fifty per cent, are the most convenient, and have given us 
very good results. We can join our observations with those of Sacazo, 
Magnol, Georges Thibierge, LePileur, Jullien and many others, who 
have had large experience in this method of treatment of syphilis, and 
accept the conclusions of Lang, that it has given us unusually satis- 
factory results in a great number of cases. We have made it the routine 
treatment of the syphilitic patients, in private practice, in clinics and 
also in the hospital wards. It is also the method which is mostly 
preferred by the patients, avoiding the trouble of taking so much 
medicine, which they say spoils their stomachs, also avoiding the 
soiling of the clothes, as in the inunctions, and they can keep their 
secret trouble from the observation of others. 

The method by injections has been severely blamed for producing 
infiltrations, abscesses, and embolus of the lungs. In our practice, 
clinics and hospital, we must confess that once in a while some abscess 
occurs from gray oil injections. In private practice, where we have 
given the injections we have had, in several thousand cases, but very 
few cases of abscesses, and even in the clinics, where we let the students 
give the injections, we have seen only a few of them formed. In the 
hospital wards, where the nurses give the injections, in the male 
department we only remember to have seen one or two cases of 
abscesses, while in the female department we were obliged to stop for 
a while this method of treatment for the reason that every injection 
became an abscess. Before using the gray oil, it is necessary to see 
that it is perfectly fluid and sterilized, that the syringe is sterile, and 
that the skin where the injection is applied is thoroughly washed with 
alcohol. In some cases a few days after injecting the gray oil there 
remains in the depth of the tissues a hard lump which, however, does 
not produce pain, and gradually disappears. In most of the cases no 
hardness remains and the patients scarcely remember where the in- 
jection is to be made. 

In the selection of the method we do not find much influence in 
the different seasons, and we try to adapt the method of treatment to 
the exigencies of the affection, and possibly to the convenience and 
to the conditions of the patient. In fact, we find patients who cannot 



204 THE MEDICAL ASPECTS 

come to the office frequently enough to take the injections, others are 
so sensitive that they cannot bear the little prick of the needle without 
suffering, and for this reason we are quite often compelled to choose 
another method. 

The time to continue treatment is one of the most important points 
which we try to impress on our patient, in order that he may not 
neglect to be treated, although he thinks he is well. We have already 
stated that, at the period of invasion of the syphilitic constitutional 
symptoms, we give our patient a solution of I per iooo of sublimate, 
and soon after we begin with the injections of gray oil. In ordinary 
cases we give injections twice a week for two weeks, and then one 
injection per week until we reach the number of fifteen. Usually all 
symptoms have disappeared by this time, and we stop the injections 
and also the solution of sublimate, for from two to four weeks. 

After this time of rest, if no other cutaneous symptoms are present 
and there remain only few mucous patches of the mouth, we prescribe 
the pills of protoiodide, which the patients take intermittently from 
three to four weeks, with two weeks rest. If other cutaneous eruptions 
appear we stop the protoiodide and resume the injections with gray 
oil, from two per week at first and then one per week, giving in all 
twelve injections more. 

In the second year the treatment is subject to the symptoms, and 
to the tolerance of the patient. If no symptoms are present the patient 
continues with the protoiodide pills in an intermittent manner, or if 
symptoms of the mucous membranes of the mouth and throat keep 
appearing, it is better for him to take the solution of sublimate. In the 
second year we give two more courses of injections of gray oil con- 
sisting of eight injections each. If it is possible at the end of the 
second year, we let our patient take a course of twelve inunctions 
with mercurial ointment. 

The treatment is entirely subject to the appearance of the symp- 
toms. In many cases the patients, as soon as they see no more erup- 
tions, cease to come and also stop taking medicine. Then they come 
back with new eruptions, with some more severe symptoms on the 
mucous membranes, and in these cases we must insist on the injections 
or on the inunctions as long as symptoms appear. In some cases after 
five or six years of good and well-directed treatment, symptoms are 
still persistent, and treatment must be kept up with courage and firm- 
ness. In some cases after ten or twelve years, especially when the 
treatment has been neglected in the beginning, it is necessary to con- 
tinue with heroic medication, in order to subdue the persistently 
relapsing symptoms. 

We excuse ourselves from speaking of idiosyncrasy for the 



THE TREATMENT OF SYPHILIS 205 

mercury, because so far a true case of so-called idiosyncrasy has never 
come under our observation. If the patient could not swallow liquor 
VanSwieten, we have given him pills ; if he could not stand the pills 
w T e have given him injections or rubbing, until we have found the way 
to administer the remedy without making it hard for the patient to 
take the medicine. We recognize that the patients addicted to the 
use of alcoholics, and those who are very anemic, cannot stand the 
remedy well, and must be continually watched on account of stomatitis, 
which unexpectedly interrupts the medication. 

Sometimes the anemia appears suddenly during the treatment, and 
then it is necessary to abandon the latter. Bad hygienic conditions, 
disturbances of the gastro-intestinal tract, and especially tuberculosis, 
are the predisposing causes. Indeed, tuberculosis is the most dreadful 
complication of syphilis, and when it has produced an anemic condi- 
tion, it is necessary to be careful in the administration of mercury. 
There are also cases of tuberculosis complicated with syphilis, which 
under the mercurial treatment have shown remarkable improvement. 

PHYSIOLOGICAL ACTION OF MERCURY 

Any way the mercury is administered, it is introduced into the 
system by the fluids of the body, is brought into the general circulation, 
and is then expelled into the secretions and excretions. Through the 
circulation it reaches every organ and we can say every tissue, but it 
is not found in them in an equal amount. According to the studies of 
E. Ludwig, E. Zillner, K. Ullmann 24 and J. Pal, the greatest amount 
of mercury is found in the kidney, next in the liver ; the bile, however, 
contains only small quantities. The intestines and the spleen have 
shown large quantities of mercury, while the bones, muscles, brain 
and lungs contain very small quantities. Under mercurial treatment 
the blood always shows the presence of mercury, as it has been found 
by Welander 25 after the inunction treatment. 

Mercury is found in the secretions, so it is detected in the saliva, 
in the sweat, in the bile and in the milk. It leaves the system through 
the excretions, and has been demonstrated in large quantities in the 
urine and in the feces. Indeed, a few hours after the introduction of 
mercury into the organism, it has been found in the urine, especially 
if it has been given by subcutaneous injections or by inunctions. The 
absorption of calomel administered through the mouth is well known, 

24 Quoted by Lang. "Acquired Syphilis." Twentieth Century Practice, vol. 
xviii 

25 Welander. " Untersuchungen iiber die Absorption und Elimination des 
Quecksilbers bei der unterverschiedenen Verhaltnissen ausgefuhrten Einrei- 
hungscur." Arch, fur Derm, und Syphilis, 1893. 



206 THE MEDICAL ASPECTS 

and cases of stomatitis have quite often followed a dose given as a 
laxative. In our own practice a patient affected with nephritis took 
some six grains of calomel in small and repeated doses for diuretic 
purposes, and three days afterward he was affected with a severe case 
of stomatitis. 

The presence of mercury in the urine is not temporary, but is 
constantly found while taking the remedy, and also sometimes after the 
patient has terminated his treatment. A certain quantity of mercury 
is retained by the tissues, where it remains for a long time. Landsberg 
demonstrated the presence of mercury in the urine ten months after 
having discontinued the treatment, and Welander found mercury in 
the same excretion from six to twelve months after the last mercurial 
inunction. Lang in two patients was able to demonstrate mercury in 
the urine seventeen and twenty-three months respectively after the last 
injection with the gray oil. 

From all the observations referred to we can with certainty assert 
that mercury administered in any form and by any method is posi- 
tively absorbed, that a great quantity of mercury is eliminated from 
the system through the urine and the feces, but that a certain quantity 
is retained in the tissues of the skin. 

Now the question comes how mercury acts on syphilis, or in other 
words, in what way it causes the regression of the syphilitic symptoms. 
The scientific world had for a long time accepted the theory of Mialhe, 
that every mercurial preparation, before it displays any therapeutic 
action, must be changed into sublimate, and that as such would attack 
with its poisonous properties the syphilitic germs forming albuminate 
of mercury and in this way carry them away from the system. 

The opinion of Boerhaave, however, could not be forgotten ; he 
claimed that the action of mercury was a mechanical one, and that the 
mercury acted as infinitely small globules in the blood and in the tissues, 
affecting the virus of syphilis. This question was recently resumed 
by J. Justus 26 who, in order to investigate how mercury acts on the 
syphilitic lesions, followed, on the one side, the histological changes, 
and on the other the biochemical alterations as they occur in the 
papula, the true and characteristic syphilitic manifestation. He excised 
papules, especially of the moist kind, in sixty different patients, and 
of these made a series of sections. Under the mercurial treatment he 
found that the characteristic infiltration made up by the numerous 
small leucocytes gradually disappeared and the plasma cells were no 
longer found, as they are converted into connective tissue fibres. The 

26 Justus, J. " Die Action des Quecksilbers auf das syphilitische Gewebe, ein 
Versuch zur Losung der Frage nach dem Wesen der Specifischen Therapie." 
Archiv. fur Derm, und Syphilis, B. 57. 






THE TREATMENT OF SYPHILIS 



207 



same changes occur inside of the blood vessels, which have been af- 
fected by syphilitic angioitis, where the infiltrating cells are reabsorbed, 
and the plasma cells are changed into fine connective tissue elements. 
These changes took place in the syphilitic papules, not through the 
constitutional treatment alone, but also through the local application 
of mercurial preparation on the syphilitic lesions. In order that he 
might find the globules of mercury in the tissues and in their cells, he 
treated the excised papule for one to two days in a solution of fourteen 
per cent, of chloride of zinc, and after washing, exposed the specimen 
for several hours in a solution of sulphurous acid, where constantly 
fresh gas was maintained. The specimen so treated was then hardened 
in alcohol, mounted in celloidin and then cut in sections. Under the 
immersion lens the plasma cells showed a large quantity of small black 
granules, with a remarkably diminished affinity for the ordinary stains. 
Moreover, in the specimens were found granules of sulphide of mer- 
cury of different sizes, scattered about in the thick connective tissues, 
and in the elastic fibres of the deeper layers of the derma. Some discol- 
oration was found in the endothelium of the blood vessels. Justus, judg- 
ing from his observations, believes that mercury is taken into the 
circulation as such, and displays its action at first on the endothelium 
of the blood vessels, and secondarily through them it is carried to the 
cells of the syphilitic infiltrations. It is taken up by these cells and it 
is combined with their albumin. In this biochemical combination mer- 
cury re-enters the lymphatic system and reaches the excretory organs, 
taking away those albuminous productions, results of its action on the 
syphilitic infiltrations. In the same way mercury is combined with 
the hemoglobin of the red corpuscles, and destroys a great number of 
them, but it attacks only those red corpuscles which have been already 
degenerated on account of the deleterious action of the syphilitic virus. 
In a like manner in regard to the tissue cells in the syphilitic lesions, 
mercury attacks their protoplasma only when they have undergone 
syphilitic alterations. The infiltrating cells, which are the result of the 
deleterious action of the syphilitic germs, have very little resistance, 
and mercury easily combines with their albumin, destroying them and 
so rendering them easily absorbable by the lymphatic vessels, and then 
they are carried away from the system through the excretory organs. 
The same experiments were, after a while, repeated by Pollio. 27 
He excised moist papules in patients after they had received two, six 
and twelve injections each with two grains of salicylate of mercury. 
without having used local treatment. After treating the specimens in 
the same was as Justus, he found the same dark granules in the syphi- 

27 Pollio. " Ueber die Aktion des Quecksilbers auf das syphilitische Gewebe." 
Archiv. fur Dermat. und Syphilis. 1902. Bd. 60. 



208 THE MEDICAL ASPECTS 

litic tissues, but they were not in any relation with the quantity of 
mercury injected. He, therefore, also began to study non-syphilitic 
tissues, which he treated with a solution of chloride of zinc, and then 
exposed to the action of the sulphurous acid. They too showed the 
same abundant black granules. Therefore Pollio came to the con- 
clusion that the presence of those black granules in the tissues was not 
produced by globules of mercury, but was a precipitate of the chloride 
of zinc, which is found in all tissues treated in the above mentioned 
manner. 

If w r e cannot, at present, establish with certainty the action of 
mercury on the sy^philitic tissues, w T e can say that mercury is a specific 
for syphilis, and that any case of syphilis, at any period, will yield to 
its action. Its action on syphilitic tissues is so well known and so 
decisive that in case of doubt between a syphilitic ulcer and another 
kind of ulcer, the test of the mercurial treatment will clear the diag- 
nosis. It is necessary to know how to handle the remedy, its energy 
of action, its indications and contraindications, the value of the different 
preparations and the various methods of administration, in order that 
we may apply the treatment to the different cases with success. If 
mercury would give success by administration through the stomach 
alone, without any other care, any nurse or druggist would be able to 
cure syphilis by giving to the patient a vial of mercury pills. But in 
our practice we see quite frequently disastrous results from so reckless 
an administration of the remedy. 

Stomatitis. — The most annoying trouble caused by the mercurial 
treatment is salivation, which comes suddenly in spite of all the care 
and attention given to the mouth. In some cases it may be considered 
as a sign of a sufficient mercurialization, and then it is necessary to 
discontinue the mercurial treatment and energetically treat the stoma- 
titis. In this affection of the gums we see an inflammation which is 
caused by the irritant action of the mercury in the saliva as a predis- 
posing cause, but as the determining cause we must see the presence 
of bacteria, which produce inflammation of the tissues already altered 
by the elimination of mercury. This condition is shown by the peculiar 
metallic taste which is complained of by the patient in the beginning 
of the stomatitis, together with an exaggerated flow of saliva from the 
mouth. The gums, especially of the lower jaw T , appear somewhat red 
and at the point where they are attached to the teeth show a kind of 
grayish line formed by some exudation. The gingival pyramids be- 
tween the front teeth are swollen, and also the hard palate behind the 
incisors. In some cases only the gum surrounding the last molar is 
affected ; it appears swollen and detached from the crown of the teeth. 



THE TREATMENT OF SYPHILIS 209 

In severe cases the process may involve the borders of the tongue, the 
cheeks, the lips and also the tonsils, at times in patches, and at times 
in large surfaces. On account of the swelling- the teeth show inden- 
tations on the borders of the tongue, and on the mucous membrane of 
the cheeks, with resulting ulcerations. The odor exhaled from the 
mouth is disgusting and unbearable. In some grave cases the affection 
spreads to the periosteum of the alveoli, which causes the teeth to be 
pressed out of their sockets. This condition gives the patients the 
idea that the teeth are elongated. The teeth may become loose and 
fall out. In some cases the inflammatory swelling of the soft parts 
may produce extensive gangrene. 

Fortunately cases of this kind occur very rarely to-day, for the 
reason that the mouth is constantly watched during the mercurial treat- 
ment, and as soon as symptoms of stomatitis appear the treatment is 
suspended, and the stomatitis is energetically treated. We can say 
that in our clinic, hospital and private practice in a large number of 
syphilitic patients, mercurial stomatitis occurs very rarely. According 
to our observations, cases of stomatitis have occurred mostly as a 
consequence of taking pills of protoiodide of mercury, or of the injec- 
tions with calomel, and of the inunctions. While during the treatment 
w r ith sublimate solution, either taken through the mouth, by baths, or 
by injections, and with gray oil injections, we have very seldom found 
cases of salivation. Of the cases of gangrenous stomatitis which have 
come under our service, one has been under the treatment of a quack, 
who claims to treat syphilis by vegetable products, and another was 
treating himself with protoiodide pills of mercury in enormous doses. 
We have also observed a case of severe stomatitis with a necrotic con- 
dition of the whole mouth and of the tonsils, in a boy twelve years old 
affected with pseudo-leukemia, who showed unmistakable symptoms of 
hereditary lues. He received two injections with five minims each of 
50 per cent, gray oil at intervals of three days one from the other. On 
account of his extreme anemic condition the mercurial treatment was 
stopped and changed to that of iron tonics and arsenic. Nearly three 
weeks after the two injections he showed signs of severe stomatitis. 

In some cases salivation occurs after small doses of mercury, but 
it usually appears during mercurial treatment ; cases occur where 
stomatitis comes some weeks and even a month after mercury has been 
discontinued, as observed by Jullien. 

As a prophylactic means for stomatitis, we observe cleanliness of 
the mouth, and as stated, in the hospital and in the clinics we have 
tooth brushes which are given to the patients, and tooth powder also 
for their use. The patients who have stumps of decayed teeth are 
referred to the dental college to have their teeth placed in good order. 



2IO THE MEDICAL ASPECTS 

As soon as we notice the gums of the patient have become red and 
the patient speaks of a metallic taste in his mouth, we stop immediately 
any mercurial treatment and also external mercurial applications. The 
patients then receive an iron tonic treatment internally and hot baths 
to promote sudation. A solution of chlorate of potassium in pepper- 
mint water is given to rinse the mouth twice a day, and during the 
time the patient uses a solution of a few drops of tincture of myrrh in 
water. In severe cases it is necessary to touch the gums and the 
ulcerated patches with a solution of nitrate of silver three per cent, or 
with tincture of iodine, or to tampon with pieces of iodoform gauze, so 
as to prevent the ulcerated surfaces from touching each other. 

The injurious action of the mercury is sometimes displayed on the 
gastro-intestinal tract, in the form of a catarrhal condition. The di- 
gestion is then disturbed, the patient suffers colicky pains, has fre- 
quent watery stools, and sometimes also with some blood ; it is a form 
of mercurial dysentery. The intestines are the chief emunctory for 
the excretion of mercury, and they are liable to feel its effects in 
whatever way it is administered. The stomach, especially through the 
administration of the sublimate, is affected with acute and chronic 
dyspepsia, which compels us to discontinue the use of the remedy. 

In several hundred syphilitic patients which we have treated in 
the manner above described, we can assert that very seldom has it 
occurred that we have been compelled to stop mercurial treatment on 
account of mercurial dysentery. 

Mercury also acts injuriously on the kidneys and there have been 
cases of albuminuria and cylinduria which have been cited as conse- 
quences of mercurial treatment. According to Welander and Lang, 
these conditions of the kidneys, with the exception of cases of excessive 
abuse of mercury, were only temporary symptoms, which are not 
accompanied by any detrimental results to the organ. We remember 
a medical gentleman who had suffered from albuminuria since his 
boyhood, as a consequence of scarlet fever, who was affected with 
syphilis. He came under our treatment and he was greatly concerned 
about the injurious action of mercury on his chronic albuminuria. We 
treated him with intramuscular injections of a one per cent, solution 
of sublimate. We examined his urine every day during treatment, and 
we saw no change in the quantity of the albumin. The gentleman got 
well without experiencing trouble on the part of the kidneys. 

As consequences of mercurial poisoning there have been mentioned 
disorders of the nervous system, and of the voluntary and involuntary 
muscles, tremores mercuriales. In cases of acute hydrargyrosis it may 
develop a real polyneuritis. Cases of this kind have been observed as 
the result of mercurial poisoning in consequence of handling mercury 



THE TREATMENT OF SYPHILIS 211 

in professional work, and only exceptionally following the therapeutic 
use of it. 

MERCURIAL POISONING 

When we referred to the method of inunctions with mercurial 
ointment we pointed out frequent eruptions caused by the irritant 
action of the mercurial ointment on the skin. We must, however, 
mention some peculiar toxic erythema, which sometimes is observed 
as a consequence of medicinal hydrargyrosis. In these cases the erup- 
tion is no longer the result of the local irritation, or of local poisoning, 
but it is due to the general action of mercury, as it occurs after its 
internal, or its subcutaneous administration. The eruption occurs in 
the form of erythematous patches, oval or discoid in shape, sometimes 
raised up and resembling a wheel of urticaria. Small purpuric spots 
the size of a pin-head are found mixed up with the erythematous 
patches, more frequently on the legs. In some cases the erythema 
assumes a fiery red color, with exudations, which raises up the epi- 
dermis in the form of blisters. Fever accompanies this eruption, to- 
gether with anorexia and general depression. The course is rather 
acute, the inflammatory symptoms soon subside, and abundant desqua- 
mation on the affected region ends the affection. In our practice we 
have but rarely seen cases of toxic erythema due to the use of mercury. 
It is difficult to explain how mercury, which is in general so well tol- 
erated in the medicinal doses, can, in certain cases, have such injurious 
results as to produce even death. Nicolich reported the case of a 
robust man who was addicted to the use of alcohol, and who died after 
the sixth inunction of mercurial ointment. Lesser 28 reported another 
case of fatal poisoning in a woman following the administration of 
two and one-half decigrams of salicylate of mercury in three separate 
injections. These unfortunate results are to be explained only from 
the standpoint of an excessive intolerance for mercury, which in most 
of the cases is caused by tuberculosis, malaria, alcoholism, degenera- 
tion, anemia, hemorrhagic diathesis, and all individual conditions which 
have influence on the production of the toxic effects of mercury. For 
this reason, when we find individuals poorly nourished, with scrofu- 
lous habit, who are suffering with suppurations, we must be careful in 
the administration of mercury. In these cases a tonic treatment asso- 
ciated with the use of iodine will improve their general nutrition, and 
then they will be able to stand the use of mercurial preparations. 

We have never seen dangerous symptoms from mercurialism in 
our practice, and we can say that when the necessary precautions are 
taken there very seldom occur the unpleasant results to which we have 
referred. 

28 Lesser. Berliner Dermat. Gesellschaft. 4. Marz, 1902. rep. Monatsheft. 
filr prakt. Derm., April, 1902. 



212 THE MEDICAL ASPECTS 



THERMO-MINERAL BATHS 



The application of hot baths and a milder climate make the 
elimination of mercury from the system more active, and in conse- 
quence the doses can be pushed to a somewhat greater extent, and so 
obtain more ready results. For this reason there have been established 
many thermo-mineral bathing resorts, which are considered, or at least 
advertised, as the Mecca of the syphilitic patients. 

In the United States we have Hot Springs, Arkansas, where a 
sulfosaline water comes out of the ground at a temperature of 120 
to 130 F. This is taken from the different bath houses, hotels and 
sanitary establishments, and is used for drinking and for bath purposes 
at the temperature at which it comes from the ground. The patient 
takes his bath at first at a temperature of 96 °, which is gradually 
increased to ioo°, and more if the patient can bear the temperature. 
His head is refreshed with a towel dipped in fresh water. The per- 
spiration begins to run abundantly from his body, and after ten or 
fifteen minutes he is taken out of the bath, rubbed dry, and left for 
a few minutes' rest on a couch. After he has taken some rest the 
attendant rubs him with mercurial ointment from one and one-fourth 
drams to two drams for from fifteen to twenty minutes. The rubbed 
regions are then covered with a piece of lint or with a piece of linen, 
and then bandaged. This treatment is repeated every day or every 
other day, according to the gravity of the case. 

We have already expressed our opinion in reference to the thermo- 
mineral cure of syphilis, and we consider it good only as an auxiliary 
treatment, helping to improve the general nutrition. Indeed, the 
Southern climate, the tepid air and the blue sky cheer up the patient, 
and his appetite increases and helps to make him stronger and better 
able to stand the mercurial applications. Moreover, the hot bath in- 
creases the functions of the skin, provokes abundant perspiration, and 
helps the excretion of mercury. For this reason we believe the ther- 
mo-mineral cure to be a valuable auxiliary in the treatment of syphilis. 

We do not believe in any medicinal property of the water of Hot 
Springs, but only in the effect which is obtained from the hot baths. 
This is sometimes abused so much that patients have become neuras- 
thenic from the weakening action of the hot water. We remember 
some of our patients affected with secondary syphilis, who, under the 
impression that in Hot Springs they would have been cured much 
more quickly, went there, and came back in a neurasthenic condition. 
They could neither sleep nor eat, their pulse was very quick, and in- 
stead of gaming, they had lost considerably from the abuse of the hot 
baths. In the tertiary period of syphilis, when the patient needs rest, 
better climate, and strong mercurialization, we have seen much better 



THE TREATMENT OF SYPHILIS 2 H 

results from the thermo-mineral treatment. Indeed, if we are not much 
inclined to send our patients to Hot Springs during the secondary 
period of the disease, we find it advisable to send the patient there 
when he is threatened by symptoms of the nervous system, or by a 
degenerative condition of the internal organs. 

IODIDES 

The other remedy which has proved so valuable in the treatment 
of syphilis is iodine, which has been used as such ever since its dis- 
covery in 1811. We must be grateful to William Wallace, of Dublin, 
who employed iodide of potassium in syphilis, and was the first to 
point out its energetic action against the malady. In 1836 he published 
in the Lancet the results of his experience with the new remedy. To 
Ricord, however, is due the credit of having studied more thoroughly 
the action of the iodide of potassium, and having limited its applica- 
tion to the special line of the tertiary syphilitic manifestations. The 
iodide of potassium is a remedy that is easily absorbed and immedi- 
ately spread into the system. Twenty minutes after taking a dose of 
iodide of potassium it can be demonstrated in the urine. 

It shows the most remarkable action upon the syphilitic infiltra- 
tions of the tertiary nature, which soon dissolves and causes their 
absorption. It relieves pains produced by specific inflammatory process 
either of a neuralgic form or of a continuous boring nature, as in 
cases of exostosis. We have seen cases of phagedenic ulcers destroy- 
ing the skin stop their destructive action and heal up under the 
influence of this powerful remedy. In cases of syphilis of the nervous 
system the action of the iodide of potassium is absolutely wonderful. 

For a time there was the belief that iodide of potassium acted so 
well on syphilitic lesions for the reason that it had the power to set 
free the mercury which had been previously taken. Mercury would 
accumulate in the system and remain inert, and the iodide of potas- 
sium would exhume this mercury and set it to work. This, however, 
is not the case, because, as Fournier wisely remarks, the iodide of 
potassium has produced its beneficial effects in many cases of late 
lues where mercury had never been given. 

According to Lesser, 29 the iodide of potassium would circulate in 
the blood not in the form of an organic combination, but as an alka- 
line iodide, and its action is due to its combination. He claims, too. 
that the iodipin, which is a combination of iodine with oil, on pene- 
trating into the tissues forms alkaline iodides and in this way displays 
its beneficial action. Sellei, 30 following the ideas of Richet and R. 

29 Lesser. " Ueber das Verhalten der Iodpraparate, speciell des Iodkaliums 
und Iodipins im Organismus." Arch. f. Derm. u. Syph. Bd. 64. H. 1 and 2. 1903. 

30 Sellei, Joseph. " Beitrage zur Frage der Wirkung der Iodalkalien und des 
Iodipins bei Syphilis." Monatsheft. f. prakt. Derm., June, 1902. 



214 THE MEDICAL ASPECTS 

Balint, that in the administration of the bromides, removing chlorides 
from the diet, the system becomes much more sensitive to the action 
of the first, believed that the same could have been true for the ad- 
ministration of the iodides. He found, however, that a diet rich in 
chlorides has no influence whatever in preventing iodism, and also 
that a diet with less chlorides does not increase the action of the 
iodides. 

We can say in general that the iodide of potassium is usually well 
tolerated, although in large doses it does not badly affect the stomach ; 
on the contrary there are cases where it increases the appetite. In 
our experience we give iodide of potassium in the clinics, in private 
practice and in the hospital in large doses with beneficial therapeutic 
effects, and without any bad consequences from its administration. 
Yet once in a while cases occur where a small dose of iodide of 
potassium has been the cause of much trouble. 

Quite frequently patients taking iodide of potassium complain of 
a salty or metallic taste in their mouths. Ladies especially, who are 
taking iodide, complain of this bad taste, which is more annoying in 
the morning and which they attribute to bad breath. Many others 
complain of cold in the head; they find a stubborn flow of mucus 
from the nose, coryza iodic a, which like any other coryza is accom- 
panied by a sensation of obstruction of the nose, sneezing and a dull 
headache. Yet this iodic coryza does not last during the whole treat- 
ment, usually the patients acquire a certain tolerance for the drug, and 
the affection becomes scarcely noticeable. 

Nearly everybody under the treatment of iodide of potassium 
shows acne pustules on the face, which resemble an eruption of acne 
vulgaris. The eruption is made by a limited number of small red 
papules surmounted by a small pustule, which on breaking forms 
small crusts. The number of the pustules is limited to a few which 
easily heal, but the persistency with which they return, especially on 
the face, forms for the patient a disagreeable feature of the treatment. 

But this is not all ; we have seen eruptions from the iodide of 
potassium attaining enormous proportions, in the form of large red 
pustules associated with edema of the face. In other cases large 
pustules were coalesced and were covered with thick crusts resembling 
somewhat a papulopustular syphilide. It is remarkable that these 
eruptions did not come after the drug was used for a long time, but 
only a few days after the iodide treatment had been commenced. In 
consequence of the use of the iodide of potassium, bullous eruptions 
have appeared, which have been described under the name of iodide 
pemphigus. The bullae resting on swollen surfaces are found mostly 



THE TREATMENT OF SYPHILIS 



**5 



on the face, neck, and some on the arms and hands. Other types of 
eruptions from the iodide have been described, in the form of thick 
pustular eruptions, and others somewhat ulcerated, where it was dif- 
ficult to differentiate the iodic eruption from a syphilitic eruption. 
Carl Berliner 31 refers to several cases in his practice of patients over- 
loaded with iodide preparations, for the reason that the lesions caused 
by the iodide had been mistaken for syphilitic eruptions. Douglas W. 
Montgomery 32 described a tuberous eruption from iodide of potas- 
sium, which simulated histologically an epithelioma, showing ulcera- 
tions on a swollen base. 

Another order of troubles caused by the iodide of potassium, 
although fortunately rare, is an edema of the respiratory tract, which 
.we have had occasion to observe several times. The edema affects the 
larynx and extends to the trachea and also to the mucous membrane 
of the bronchial tubes. The affection is one of an inflammatory nature 
and caused by deep alterations of these organs. Fournier 33 refers to 
some cases, which have ended fatally, where the post-mortem showed 
edema of the upper portion of the larynx, of the vocal cords, of the 
epiglottis, accompanied with an acute congestion of both lungs. The 
few cases we have had under our observation have all recovered, but 
have caused sufficient fright to the internes and to the nurses. We 
remember a patient, a butcher by trade, who came into our private 
practice with symptoms of tertiary syphilis. We prescribed for him 
a saturated solution of potassium iodide to be taken in ascending dose, 
beginning with ten drops after each meal in water. He took ten 
drops after his breakfast and ten drops after his dinner, and was soon 
after affected with flushing of the face, swelling of the eyelids, diffi- 
culty of respiration, aphonia, all owing to the edema glottidis, which 
fortunately on account of the small dose was not so serious as to 
menace his life. 

We do not know exactly the reason why the iodide, so valuable ? 
remedy in some cases, acts so strangely as to jeopardize the life of the 
patient in others. It has been attributed to the quality of the drug, to 
to impurities contained in it, but the same drug has never produced 
any trouble in other patients, who were taking the remedy out of the 
same bottle. It has, therefore, nothing to do with the quality and the 
purity of the remedy, but the reason must be sought rather in the 
individual condition of the patient. Someone has advanced the theory 

31 Berliner, Carl. " Zur differential Diagnose der Syphilis und syphi- 
lisahnliches Arzneiexantheme." Monatsheft. fur prakt. Derm., 15 Aug., 1902. 

32 Montgomery, D. W. The Journal of Cutaneous Diseases, February, 1904. 

33 Fournier, Alfred. " Traitement de la Syphilis." Paris. P. 415. 



2l6 THE MEDICAL ASPECTS 

that the iodismus is connected with some trouble of the kidnevs and 
is due to a scanty elimination of the remedy by the urine. In our 
cases, however, this theory cannot be admitted, when we had symptoms 
of edema glottidis after the ingestion of fifteen grains in two doses, and 
in other cases also after smaller doses. In these cases the accumula- 
tion of the remedy is entirely out of the question. It is necessary, there- 
fore to admit, with Fournier and others, the existence of an individual 
idiosyncrasy for the remedy, which in a few individuals is capable 
of bringing about such dangerous symptoms. For this reason we 
always recommend that our patients begin the treatment of the iodide 
of potassium with small doses of from five to ten drops of the saturated 
solution three times a day diluted in a large quantity of water. When 
we have tested the tolerance for the remedy, then we begin to increase 
the dose, bringing it up to large quantities per day, according to the 
indications of the individual case. 

Although the iodide of potassium has been administered hypo- 
dermically and by rectal injections, yet we have always preferred the 
method of ingestion. We have never found a patient who could not 
swallow the solution of iodide, especially when diluted in large quan- 
tities of water. In many cases we advise our patients to dilute their 
medicine in half of one cup of milk, which is easily taken and does 
not produce any irritation on the stomach. 

In case of a dyspeptic condition, when the stomach cannot retain 
the solution of iodide, we can give it associated with an elixir of 
pepsin, or in some more palatable formula. The following has been 
recommended by Fournier : 

Potass. Iodide 25. 

Anisette de Bordeaux 150. 

Syrup Simpl ' 350. 

M. 

It is also recommended to dissolve the daily dose of iodide in a 
sufficient quantity of water, which is used for drinking purposes during 
the meals. In this way the remedy is taken with the food, and will not 
produce any irritation of the mucous membrane of the stomach. 

We always avoid the use of the iodide in pills, for the reason that 
the pill dissolving in one part of the stomach is capable of irritating 
the part of the mucous membrane which it touches. 

In reference to the doses of the iodide, they are different, accord- 
ing as it is used in a preventive or in a curative way. In our practice 
we do not use the iodide of potassium unless it is late in the treat- 
ment. This remedy, although a very valuable one, must not, in 
ordinary cases of early syphilis, be used. It finds, however, indica- 
tions in some special cases of early syphilis when its invasion is accom- 



THE TREATMENT OF SYPHILIS 



217 



panied by acute rheumatism, pain or severe headache. In these cases 
it is the most valuable remedy for relieving the pains. When the 
patient begins to show signs of inflammation of the periosteum, the 
only remedy to relieve the nocturnal pains is the iodide. But if there 
are no such indications, the treatment of syphilis in its early period 
is based on mercury, and this is the only remedy. 

When our patient has taken mercurial treatment for a year and 
we do not see other symptoms, then we give him some iodide treat- 
ment for a preventive purpose. In this case, we begin with the dose 
of ten drops after each meal, and gradually increase it to twenty-five 
and thirty drops in half a glass of water. This is an ordinary dose ; 
but when we have to do with cases where the nervous system is 
threatened, where we need a prompt therapeutic action, then the dose 
will be at first from two drams to four drams per day, but such ex- 
ceptional doses as mentioned before have to be reserved for excep- 
tional cases only. Indeed, Fournier very wisely remarks in reference 
to these high doses, that it is of no use to give ten bottles of Seidlitz 
to purge a patient, when we can obtain the effect with an ordinary dose. 

In individuals who have been badly affected by the iodide of 
potassium, or when the dose has to be increased to a very high degree, 
we have used the iodide of sodium, which is somewhat milder in its 
effects. We find that it is better tolerated, is less depressing, less 
irritating, and does not act so severely on the kidneys. Its action, 
however, when compared with that of the potassium iodide, is less 
reliable, so that we use it only exceptionally in our practice. 

We can say that a valuable addition has been recently made to 
the iodides therapeutic by the use of iodipin. This is a combination 
of sesame oil and iodine and it is prepared in the strength of ten and 
twenty-five per cent. The idea comes from Winternitz, 34 who was 
trying to obtain a preparation where the iodine could be combined with 
an organic substance, and from which it could not easily be separated. 
The symptoms of iodismus, having their cause in the iodine free from 
its alkaline combination, led him to think of a preparation which 
could be carried to the affected tissues, maintaining the iodine strongly 
combined. One combination of iodine with albumin gave the iodal- 
bacid, and the other with oil gave the iodipin. According to Noble 
and Welander, a short time after the ingestion of an alkaline iodide, 
free iodine is found in the saliva and in the urine, and they rightly 
attribute to the free iodine the therapeutic efficacy of the remedy. 
The action of the alkaline iodides is not very permanent, because after 
twenty-four to forty-eight hours nearly all the iodine has disappeared 
from the organism, very little remaining for the therapeutic appropria- 
34 Winternitz. Dentsch. Med. Wochenschr., 1897. 



2l8 THE MEDICAL ASPECTS 

tion. Consequently large doses are necessary in order to maintain a 
certain quantity of the iodides in the system. 

We can say that with the iodipin all the lamented inconveniences 
have nearly disappeared. The iodipin is prepared by E. Merck, of 
Darmstadt, and by that firm is placed on the market. The combina- 
tion is of ten and twenty-five per cent. The first is used for internal 
administration, in capsules to avoid the disagreeable taste, and the 
second is mostly used for subcutaneous injections. We have had 
experience with this preparation for over four years, and we agree 
with Klingmuller 35 that the iodipin by subcutaneous injections is to 
be considered one of the best ways to administer iodides. The method 
is easy and simple, the action of the iodides is sure, strong and per- 
manent, thus avoiding the troubles which are caused by other iodide 
preparations. In a few cases where the patient could not come to get 
the injection, we have given the iodipin in capsules, in the quantity of 
one teaspoonful per day, which has been well tolerated by the stomach 
and is quickly absorbed, without causing gastric disturbances or 
symptoms of iodismus. Frieser finds that iodipin does not set iodine 
free in the stomach, but as soon as it comes into the intestines it is 
readily absorbed. Sternberg has found the reaction of the iodine in 
the saliva, sixty-five minutes after ingestion, in case of normal stomach. 
In the few cases where we have used iodipin by ingestion it has 
rendered good services. 

The usual way of administering iodipin is by subcutaneous injec- 
tions. It is necessary to have a special syringe, much stronger and 
larger, with larger and longer needles. It has been recommended that 
the iodipin be warm before using, which we never do, as the tempera- 
ture of the room keeps the iodipin fluid and ready for use. We in- 
ject one syringeful into the scapular region every other day, or even 
every day, injecting first on one side and then on the other. We 
insert the needle from above downwards obliquely into the sub- 
cutaneous tissue, and thus the oil is squeezed into the tissues. At the 
moment of injection, the patients complain of a burning sensation, 
which in a few minutes subsides. We have never seen an abscess 
following the injection of the iodipin. In cases where we find a mixed 
treatment necessary, we reserve the gluteal regions for the gray oil 
injection, and the scapular regions for the iodipin. 

Blomquist, 36 Welander, 37 and Sellei 38 have demonstrated the 

35 Klingmuller. " Iodipin in subcutaner Anwendung bei tertiarer Lues." 
Berlin, klin. Woch., 1899, No. 25. 

36 Blomquist. Arch. f. Derm. u. Syph., 1901. 

37 Welander. Arch. f. Derm. u. Syph., 1901. 

38 Sellei. Monatsheft f. prakt. Derm., June, 1902. 



THE TREATMENT OF SYPHILIS 219 

presence of the iodine in the urine sixty-five minutes after the injec- 
tion, but in most of the cases it is found one, two or three days after 
the first injection. The presence of the iodine in the urine is easily 
found by taking a quantity of urine, six or ten gmms., to which a 
small quantity of starch solution is mixed and then well stirred. Then 
a few drops of fuming nitric acid are added, and the presence of 
the iodine is revealed through a thin veil of a blue color on the 
urine. 

The iodipin is absorbed as such from the place of injection, and 
enters into the general circulation as a firm combination of iodine and 
fat, and only in the depths of the tissues are the alkaline substances 
capable of taking the iodine from the combination, thus forming alka- 
line iodides with the alkalies of the organism. It is easy to understand 
the reason of the more permanent action of the iodipin compared to that 
of the ordinary alkaline iodides, which lose their iodine while in the 
stomach and the intestines, causing iodismus, with all the troubles we 
have above mentioned. In the cases of Klingmuller, iodine was demon- 
strated in the urine and in the saliva only two or three days after the 
first injection; and in the urine two months after the last iodipin in- 
jection there could be found traces of iodine. 

The great advantage of the subcutaneous injections with iodipin 
is that we can reach a therapeutic efficacy of the iodide treatment with- 
out exposing the patient to the inconveniences of the iodismus, and 
keep him for months under the action of the iodine, until we have 
obtained the expected results. We must state from our experience 
that the efficacy of the iodipin has been shown to be far superior to the 
ordinary ways of administering iodides. In our hospital wards 
iodipin has given us the most satisfactory results. In cases where 
a few drops of the solution of iodide of potassium could not be toler- 
ated, injections of iodipin repeated every day did not produce any 
systemic trouble, and gave the desired results. A few weeks ago a 
patient affected with syphilitic basilar meningitis, who for six months 
had been totally blind, had been treated in a sanitarium with inunc- 
tions of mercurial ointment, and with the ordinary solution of iodide 
of potassium, without results. He was brought under our treatment 
and subjected to iodipin injections; in a few days he was able to see 
somewhat, at first with only one eye, but afterwards with the other 
also. He is reported as still improving. 

The iodine treatment is usually reserved for the tertiary lues, and 
in these cases we can see its wonderful efficacy. In the cases, how- 
ever, of tertiary syphilis, where we find that the patient has taken in- 
sufficient or no mercurial treatment during the secondary period, we 
give the iodine treatment, but we cannot entirely leave off mercury. 



220 



THE MEDICAL ASPECTS 



Here we must use both remedies, the most efficacious ones we have 
against syphilis. 

In our hands the severe last cases are treated with mercurial 
ointment inunctions, and the administration of the iodide of potassium 
internally. In cases of severe affections of the nervous system, where 
an energetic treatment is required at once, we give injections with 
gray oil and injections with iodipin simultaneously. In these cases we 
give the injections of the gray oil every two days, and injections of 
iodipin every day, and even twice a day. In this way we have a 
strong and energetic mixed treatment, which has, in many cases, given 
excellent results. 

The beneficial action of this treatment, and the involution which 
it brings about in the pathologic products of syphilis is so apparent 
and sure that we have used this treatment in cases of doubt, as a 
test treatment, to ascertain whether the affection was of a specific 
nature or not. We remember an ulceration on the glans penis, stub- 
born and proliferating, which had all the appearance of a carcinoma. 
It was in a gentleman who strongly denied any possibility of infection. 
A piece was examined by a pathologist, who was greatly inclined to 
believe in the cancerous nature of the infiltration, and the amputation 
of the penis was considered the only means of saving the life of the 
patient. In spite of all his assurances that he had never had any 
syphilitic trouble, we gave him a strong mixed treatment as a test 
treatment, and an emplastrum hydrargyri on the locality. In a few 
weeks the ulcer healed up, giving us the certainty that it w T as nothing 
more than an ulcerated gumma. We know well that ulcers of a 
tubercular or of a carcinomatous nature are rather irritated than bene- 
fited by this treatment, while syphilitic tertiary processes react 
promptly under a treatment of iodides and mercury. 

In a case in which a child is born with congenital syphilis, both 
parents, although they show no apparent symptoms of the disease, 
must be subjected to a mixed treatment. In these cases when we have 
no special symptoms to fight, and when the treatment must be con- 
tinued for some time, we use a milder treatment so that it may be 
tolerated by the system for a longer time. It is necessary to give the 
patient some intervals of rest from the treatment. Although in some 
cases, obstinate symptoms have not yet entirely disappeared after 
several weeks of strong treatment, it is advisable to rest for a while 
and then begin the treatment again. In this way it will show much 
more efficacy than if continued for too long a time. 

When the symptoms have disappeared the patient cannot give up 
treatment and he must continue with the remedies intermittently. In 
the second year we continue the treatment, but stop it for periods of 



THE TREATMENT OF SYPHILIS 221 

from four to six weeks, so as to afford a rest. In the third and 
fourth year, if no symptoms are present, we advise our patients to take 
a course of treatment two or three times a year lasting six weeks. 
In some cases the mercury and the iodides are given alternatively. 
We give the patient a course of eight or ten injections with the gray 
oil, one injection per w r eek, and when he has taken the injections then 
he takes iodides for three or four weeks. 

In determining the time that the patient has to continue the treat- 
ment we are guided by the condition of the lymphatic glands. As 
long as the glands, especially of the cervical region, are enlarged, hard 
and perceptible to the exploring hand, we advise the patient to take 
a course of treatment at least twice a year. We believe in the ideas of 
Fournier, namely, that the treatment must be intermittent and must 
extend over a period of several years. Syphilis develops symptoms 
and pathological products at intervals, and in consequence the treat- 
ment must be given at intervals. When treatment is given inter- 
mittently it will not only cure the symptoms which are present, will 
not only produce the involution of the syphilitic products, but will also 
prevent possible relapses. The idea of Fournier, with his repeated 
and chronic treatment, is to prevent new outbursts of the disease. 

The objections raised by Lang to the continuance of the treatment 
for so long a time, advocating rather an opportunistic treatment, are 
not so forcible as to make us recede from our views. We know very 
well that the course of syphilis is so variable, we also know that in a 
great many cases after a very mild eruption, the disease has shown 
itself no more and it has been considered entirely cured. But we can- 
not forget that a great many of these cases, after ten or fifteen years, 
have shown symptoms of general paralysis or of ataxia. The neurol- 
ogists teach us that syphilitic diseases of the nervous system are 
mostly found in patients who had passed a very mild stage of con- 
stitutional syphilitic symptoms, and as a consequence they did not care 
much for a long and thorough treatment. 

In the matter of determining how long the patient has to continue 
with his treatment, as already stated, we must be guided by the qnality 
of the symptoms, if superficial and easily yielding to the treatment, or 
if deep, frequently relapsing, and stubborn to the action of the remedy. 
The general condition of the patient has also to be taken under con- 
sideration. A man strong and in good general condition will tolerate 
a much longer and much stronger treatment than another who is 
weak, debilitated by alcoholism or by some other diathesis. The 
patient must remain under the supervision of his physician, and as 
long as the lymphatic glands are still hard and perceptible, the patient 
needs to receive more treatment, which will be given at lono- intervals. 



222 THE MEDICAL ASPECTS 

Whenever the patient sees any lesion which reveals a possible relapse, 
he must see his physician again so as to determine whether more treat- 
ment is advisable. 

In some rare cases where the specific treatment is not easily toler- 
ated we may derive some benefit from the use of some depurative de- 
coction, such as sarsaparilla, dulcamara, etc., which in association with 
fresh air, good nutrition, ferruginous preparations, and rest from ordi- 
nary business, will improve the general system of the patient and make 
him able to stand the specific treatment. In cases of old ulcerative 
syphilis in individuals in an emaciated condition, we often prescribe 
the Zittmann decoction, which from the sixteenth century has main- 
tained its reputation. We have seen the Zittmann decoction ordered 
freely by our revered teacher, Professor F. Hebra, with admirable 
results. It is a decoction made of several different remedies ; the 
most interesting of all is the sarsaparilla, cinnabar and calomel. The 
principal action of these decoctions seems to be that of the diuresis 
and diaphoresis, causing an increase in the tissue exchanges, which is 
beneficial in the treatment of syphilis. Of course to-day nobody would 
prescribe these decoctions as the principal treatment for syphilis when 
we know that they have little action on the syphilitic infiltrations on 
account of the small quantity of calomel they contain. But they can 
still be used, as H. Zeissl 39 advises, as coadjuvants, while under the 
mercurial treatment, or after. Zittmann decoction has the following 
formula : 



Rad. Sarsaparill. cone 5 x ii 

inf. cum 
Aq. fontis ob lxxii 

diger. p. horas xxiv 

dein add intra sacculum linteum 1 

pulv. sacch, alb yaa 3 vi 

alumin. crud J 

Calomel , 3 iv 

Cinnabar 3 i 

Coque ad col. lib xxiv 

Sub finem coct. add ] 

Sem. anisi vulgaris J-aa 3 iv 

Foenic j 

Fol. sen ) _ . 

Rad Hquir |aa 3 iss 

Exprime et per pannum cola. 

This is the formula of the decoctum Zittmanni fortius, strong; 
there is another formula for the decoctum Zittmanni mitis, or weaker, 
which is as follows : 

39 Zeissl, H. " Lehrbuch der Syphilis." Erlang., 1871. 



THE TREATMENT OF SYPHILIS 223 

Rad. Sarsaparill. cone % vi 

Additis speciebus a decocti fortiore 
residuis coque cum 

Aq. font ob lxxii 

ad colatur ob xxiv 

Sub finem coctionis add. 

Cortic. f ructus citr 

Sem. Cardamom, minor 

Cortic. cass. cinnam 

Rad. liquir 

Exprime et per pannum cola. 



aa 3 iii 



These decoctions were formerly given in exorbitant doses. The 
patients after taking a good dose of calomel and jalap, were compelled 
to drink one pound of the strong decoction, hot, at once, while remain- 
ing in bed to wait for a profuse sudation and also for the catharsis. 
Every day the patients had to take such large doses of the decoction 
that in a short time they were suffering with catarrh of the stomach 
and of the bowels. In our practice we use between six and eight 
ounces per day of the strong decoction, taken half in the morning and 
half in the evening. When the patient begins to complain of diarrhea 
he must immediately stop its use. As far as experience goes, the dose 
above mentioned is well tolerated, and in cases of syphilitic cachexia, 
in patients with a run-down system, who could not bear an ordinary 
treatment, we must confess that the decoctum Zittmanni has given us 
beneficial results. 

While in Germany the decoctum Zittmanni had gained so great a 
reputation, in Italy they used the Pollini decoction, which consisted 
of nearly the same ingredients. 

A great many depurative decoctions have been placed on the 
market with different names and different trade-marks. In all, 
sarsaparilla is one of the most important ingredients, the decoctum 
Vigaroux, the syrup Cuisinier, the Roob Laffecteur, in which there 
was also some sublimate. For all these different beverages, widely 
advertised by the firms, and sometimes recommended to the physicians 
in their offices by special agents, we can say that it is much better to 
keep away from them, and remove the idea from the public mind that 
the physician recommends such and such mixtures, and therefore they 
can continue the treatment without consulting their physician. 

INDIVIDUAL PROPHYLAXIS 

In France in 1899 a pamphlet was issued under the title Hygiene 
and Morals, by the Ligue de la Moralite publique, of which Dr. Good 40 
was the author. It was purposely written for a son of sixteen, to 
explain to the male youth that sexual continence is not at all injurious 

40 Good, P. 77 Conference Internationale pour la Prophylaxie de la Syphilis, 
etc. Bruxelles, 1903. 



224 THE MEDICAL ASPECTS 

to the health, but on the contrary is greatly advantageous. That a 
young man must early have his sexual appetite satisfied is only a 
vulgar prejudice which has no scientific base, and is entirely against 
hygiene, which commands the continence of the young men. The 
idea of early satisfying the sexual appetite is that which exposes young 
men to acquire venereal diseases, which are the inevitable results of 
debauchery. This small pamphlet, written in an easy style, was soon 
translated into many languages and was distributed among young 
students, soldiers, etc., in order to place them on their guard by giving 
them a knowledge of the peril of syphilitic and venereal infection. 

Valentine 41 has followed this idea, and in a pamphlet, " The Bov's 
Venereal Peril," in plain and easy language explains to young men the 
dangers by which they are continually surrounded. Valentine, and 
with him many others, are advocating public lectures to the young 
people on these subjects. It seems, however, that conversations in this 
matter between the father, the teacher, the minister and the adoles- 
cents are more appropriate and capable of bringing about better results. 
It is a great mistake in fathers, teachers and ministers, and educators 
in general, who, knowing the necessity of placing the young on their 
guard against those monstrous diseases, yet on account of the difficulty 
of approaching so delicate a subject, or through an ill-conceived 
modesty, conceal from the young men the danger which is impending. 
The treatise on this subject, written from a purely moral and religious 
standpoint, does not bring much benefit to the young man, unless it is 
shown in its social and medical relations. The way in which young 
men reason is, " if God has forbidden intercourse between the two 
sexes outside of marriage, why has He given a want to satisfy when 
marriage is impossible?" But when we succeed in showing that this 
want is not so urgent as eating and drinking, that it diminishes the 
vital forces in the young men, that it makes them unable to follow 
their classical studies, then we impress upon them the necessity of the 
continence. The medical part is that which shows the wages of the 
sin, the awful results of syphilis in young men, and will exercise a great 
influence on them, putting them on their guard against intercourse 
with public or easy women. 

If young men do not get some knowledge in the matter of sexual 
hygiene, they will learn the opposite from some profligate companion, 
who will very likely lead them into immoral houses, and will expose 
them to the danger of venereal diseases. 

The pamphlet is considered the best means of reaching the young 
man, and the pamphlet must treat the question of sexual hygiene in 
reference to the social, moral and medical standpoint. The pamphlet 

41 Valentine, F. C. " The Boy's Venereal Peril," from the Journal of the 
A. M. A., July 4, 1903. 



THE TREATMENT OF SYPHILIS 



225 



of Good was followed by another magnificent pamphlet written by Dr. 
Fournier under the title A nos His quand Us auront 18 ans. 

For our American families and for the American boys, the 
pamphlet of our esteemed friend, F. C. Valentine, is excellent, clear, 
brief and to the point. We wish that a large number of copies of this 
article could be distributed to all high schools, universities, colleges, 
military institutions, regiments, barracks, etc., in order to reach as 
many young men as possible. Indeed, the spreading of the venereal 
diseases and syphilis is due to prostitution, clandestine and public. 
Although this danger is well known, yet all efforts against prostitution, 
as we will see later, have remained of no avail, and clandestine prosti- 
tution especially is beyond the reach of the authorities, and has proved 
to be the principal cause for spreading syphilis. 

If the young man who has never heard of these diseases and has 
been infected with syphilis, had known the gravity of this disease, the 
individual danger for his future, the danger for his family, he would 
never have gone into that house and exposed himself to the infection. 
The ignorance of the disastrous consequences of syphilis is often the 
cause why many young men expose themselves to infection. More- 
over, when they hear from the profane mouth of a companion, speak- 
ing lightly and sometimes jokingly about the loathsome ailments, they 
lose all fear, and will surely become infected. The old assertion of 
Paul proves true, that obscene talking and bad example corrupt good 
moral character. To avoid this and its sad consequences, it is mani- 
fest that young men need enlightenment so that they may be able 
to understand the peril in which they are placed in going to the 
houses of prostitution. 

Queyrat, in speaking on this important subject of the individual 
prophylaxis with reference to venereal diseases, called attention to the 
great wrong of the ministers of the Gospel of every denomination, who, 
with the efforts of their eloquence, try to demonstrate that the bodv 
is despicable matter, and only the soul is of importance. The genital 
organs they call the organs of shame, debasing nomenclature of the 
organs of reproduction, from which we come, and from which our 
children are to come, and which ought to be considered the noblest 
organs, in which the hope and the future of the race are based. The 
hygiene of the sexual organs must be taught as one of the most im- 
portant parts of the welfare of the generation. When the genital 
organs are neglected and not kept cleansed of the presence of the 
perspiration and sebaceous matters, they become irritated and inflamed, 
increasing the sexual appetite. It ought to be the duty of the family 
physician to advise circumcision in male children when the prepuce is 
too long or too narrow, when it is often the cause of general troubles. 



226 THE MEDICAL ASPECTS 

In this regard it is interesting to enter upon the old question, 
whether circumcision can lessen the susceptibility of the individual 
to syphilitic inoculation. It is undeniable that prejudice has played a 
great role, and the idea of preserving circumcision as a religious rite 
has shown great advantages based more on sentimental grounds than 
on truthful observations. In our opinion we have found initial lesions 
of the male organs among people who had been circumcised, as well as 
among people uncircumcised. From our records of many years' stand- 
ing we are unable to find any difference in the number of primary 
lesions among circumcised and uncircumcised. Moreover, we have 
found the largest number of primary hard chancres in the sulco 
balano preputiale, and only a few on the external or internal sheet of 
the prepuce. In this case circumcision has afforded very little 
protection. 

Our observations are not much different from those of Gottheil, 42 
as we agree with him that amongst the circumcised population of 
immigrants syphilis is not so common, not on account of their being 
circumcised, but on account of their earlier marriages and of a better 
standard of sexual morality. 

Breitenstein, 43 who has been a physician in the Dutch Indian 
army, referred to his experience of twenty-one years among the Euro- 
pean and Malayan soldiers. He has found that syphilis among the 
natives, who are all circumcised, is much less frequent than among 
the uncircumcised Europeans, although they are equally exposed to 
the possibilities of infection. 

There is no doubt in our mind that circumcision is desirable on 
account of cleanliness. In cases of an accumulation of the smegma, 
often balanopostitis is the consequence, with frequent excoriations of 
the internal surface of the prepuce and of the glans. This condition 
of tenderness of these parts in the case of exposure to the contagium 
will render the inoculability of syphilis certain. We know in our 
venereal wards how troublesome a long prepuce is for the treatment 
of chancres. It usually becomes edematous and cannot be pulled back 
without causing pain, and exposing the patient to paraphimosis. This 
cannot happen in circumcised persons, and from this point of view 
we can say that circumcision is an advantage as a preventive and cura- 
tive measure. 

However, as we have already said, there is no necessity for youths 
to go around and expose themselves to venereal infection ; we find 
that circumcision does not have to be practiced indiscriminately in all 
male children for this purpose. It must be practiced only on those 

42 Gottheil, Wm. S. Progressive Medicine. Vol. iii, 1903, p. 164. 

43 Breitenstein, H. Dermat. Centralblatt, ref. Monatshefte f. prakt. Derm., 
Feb., 1903. 



THE TREATMENT OF SYPHILIS 



227 



children where the prepuce is very long-, and it is consequently diffi- 
cult to clean the glans, and in all cases where the prepuce is too 
narrow. In some cases we have found that it had only a small hole, 
scarcely allowing the urine to pass. In these cases circumcision is 
not only advisable, but it must be done of necessity. 

The reading of the letter of Dr. Valentine is to be advised at the 
age of puberty, insisting always on the important point of sexual con- 
tinence and that a man ought to maintain his chastity until his mar- 
riage. Victor Hugo in his Lettres a la Fiancee wrote to Madamoiselle 
Foucher, who was afterwards Madame Victor Hugo, as follows : " Je 
considererais comme une femme ordinaire, c'est-a-dire comme bien 
peu de chose, une jeune fille qui epouserait un homme sans etre morale- 
ment certaine par les principes et le caractere connu de cet homme, non 
seulement qu'il est sage, mais encore, et j 'employe expres le mot 
propre dans toute sa plenitude, qu'il est vierge, aussi vierge qu'elle- 
raeme." 44 These few words ought to be taught and impressed on the 
mind of every young man as a protection against the silly talking of 
misguided companions. 

We can say that the true prophylaxis rests a great deal with the 
conscience of the young man. The instruction on the sanitary matter 
will make him cautious, he will try to behave himself, but if he has no 
purity in his moral principles, with all the instructions he is liable to 
fall. Indeed, boys who are raised with immoral principles are great 
sources of hygienic and moral danger among the innocent and honor- 
able in their lives. With their habits of body and mind, they are 
capable of spreading disease and corrupt thought among other boys. 

In strong and vivid colors, Valentine has brought before young 
men the dangers coming from corrupt boys. When a boy who seems 
in every respect a fine fellow is boasting among others of his sexual 
experience with girls, he must be avoided by the other boys ; they 
must know that with his lies he is trying to corrupt them. In the 
same way he points out someone, who, with improper acts, may insult 
the manhood of the other boys, and he deserves to be severely thrashed. 
Others, selling immoral books, pictures, etc., are spreading corruption 
among young men, and they must be not only avoided by moral young 
men, but also brought to justice and severely punished. 

The excitement of the sexual appetite increases the desire for 
pleasure, and exposes one to the danger of acquiring venereal diseases. 
The detriment to the individual from syphilis and venereal diseases is 

44 Translation — " I should consider an ordinary woman — which means one 
not worthy of high esteem — a girl who would marry a man without being morally 
sure of the principles and the known moral character of this man. She should 
know not only that he is wise, but also, and I use the proper word in its strict 
meaning, that he is virgin, just as virgin as she herself is." 



228 THE MEDICAL ASPECTS 

very great, and it is calculated that one-eighth of all the patients in 
the hospitals of New York are inmates of those institutions on account 
of venereal diseases or syphilis and their consequences. These, how- 
ever, who are laid up in the hospitals are only a small fraction of the 
large number of those who, being infected, are still walking the streets 
and trying to attend to their occupations. 

It is not only the uncultured and uneducated man who is the 
victim of syphilis through his unbridled passions, but also the cultured, 
educated and intellectual man is equally often so unfortunate as to be 
infected. In our experience, however, we must say that syphilitic 
infection is much more frequent in the lower classes of society, amongst 
uncultured people, than it is amongst the better classes. 

We have already seen that syphilis is a disease which can be 
contracted entirely outside of the venereal act; we have seen that 
over twenty-five per cent, of all cases of syphilis have been inoculated 
accidentally, without anything being known of the danger of infection. 
It is, therefore, the duty of the physician to instruct his syphilitic 
patient of the danger of spreading syphilitic contagium. A young 
man who has been unfortunate enough to become infected with syphilis 
must know that he cannot kiss his mother, his father, his sisters or 
brothers, because his poisoned kiss can give syphilis to those whom he 
loves best. He must not permit anyone to use cups, glasses, spoons, 
forks, etc., which he has used, if not first washed. 

When we consider how easy the transmission of syphilis is, we 
will not be so much surprised to see the spread of syphilis amongst 
innocent people in factories and in places where many people live 
together. In their ignorance, they exchange pipes, or moisten pencils, 
take tools into their mouths, use drinking cups which have been used 
by a syphilitic companion in a like manner. 

It is therefore advisable for everyone to be careful and not 
drink from a cup used by others, without having it well rinsed, to 
avoid possible infection. 

The idea of the transmission of syphilis from the infected man 
to his wife, the idea of having syphilitic babies, must remain in the 
mind of a young man. This will keep him from exposing himself to 
the contagium by fear of the danger ; but it is not all ; the most im- 
portant point is the prevention of immorality. The greatest means 
of prevention of the spreading of syphilis as an individual prophylaxis 
is morality and sobriety, which form the fundamental base of the 
family, of the state, and of society. Syphilis is a monstrous disease, 
which not only poisons the life of the unfortunate who becomes in- 
fected, but infects his family, weakens the generation, being thus a 
constant menace to the individual himself, to his family, and to society. 



XI 
THE TRANSMISSION OF SYPHILIS TO THE OFFSPRING 

DIRECT TRANSMISSION 

The question of direct transmissibility of syphilis concerns the 
duration of the period of contagiousness. It would be easily settled if 
we could be able to establish positively the duration of this period, in 
which the infected subject continues to be a possible source of con- 
tagion to others. If we were to accept the contradictory statements 
of our patients, and also the misleading reports of isolated cases re- 
ported by physicians, we should easily come to the conclusion that 
there is no limit to the duration of the .contagiousness of syphilis. 
Not rarely do patients try to disguise truth to mislead the physician, 
in order to cover some mistake of their life. 

It is a difficult task to establish a priori a certain time after which 
syphilis is no more inoculable. In our experience, we find somewhat 
risky the assertion of Hutchinson x to permit and even encourage mar- 
riage, when two full years have elapsed from the date of contagion. 
In several cases it has happened that we have made the diagnosis of 
syphilis, and the patient has been astonished, saying that his physician 
had assured him of his perfect recovery after two years from infec- 
tion. When advised to postpone marriage he has replied that he was 
already married, under the assurance of the two years' cure. 

It is not correct to state that syphilis after two or three years is 
no more directly inoculable. In our opinion, each case must be studied 
by itself, and then, according to the past symptoms, to the time 
elapsed, to the treatment employed before, and to the present condi- 
tion, we can give our advice concerning marriage. 

After the classic works of Langlebert, Velpeau, Gibert and 
Ricord, the contagiousness of the secondary manifestations of syphilis 
has been generally recognized, and to-day it is out of the question to 
say that as long as the secondary symptoms are recurring, marriage 
must be forbidden. After the initial chancre, the most dangerous of 
all syphilitic manifestations are the mucous patches, papula humida, or 
condylomata lata, which in most of the cases convey the virus to the 
other party. Physicians and laymen commonly assert that if no sore 

1 Hutchinson, J. Third International Congress of Dermatology. Transac- 
tions, 1898. 

229 



230 THE MEDICAL ASPECTS 

is present, syphilis cannot be communicated. We are of the same 
opinion, but the great difficulty is to prove that no sore is present. 
The mucous patch is formed in a moment, and the syphilitic patient, 
with the best of care, is often unaware of the existence of a patch on 
the genitals or on his lips. Mucous patches are sometimes formed on 
the back of the tongue, in the tonsils, and their secretion, virulent and 
infections, mixed with the saliva, may carry the contagium. A mucous 
patch, which is nothing more than an excoriated papula on the 
macerated skin, or on the mucous membranes, is a characteristic early 
eruption of syphilis, so that when we see one of these manifestations 
there is no doubt of the existence of syphilis. 

Some years ago we 2 published the records of syphilitic cases 
which had occurred in a period of five years in our private practice. 
Of 216 syphilitic patients recorded for that length of time in our books, 
159 were men, 51 women, and 6 infants. In order to see the frequency 
of the mucous patches in the different stages of syphilis, the cases were 
separated into those of the early period, or secondary stage, and into 
those of the late period, or tertiary stage. We have found that 116 
cases belonged to the secondary period and 94 to the late stage of 
syphilis, and 6 cases were of congenital syphilis. Mucous patches 
were present in the first period of the secondary stage in 102 patients 
of the 116, and in 24 of the 94 patients affected with tertiary syphilis, 
and in 2 of the congenital syphilis. 

This shows that mucous patches are very frequent during the sec- 
ondary stage, and they still show up in the beginning of the tertiary 
period. The anatomical regions which are affected in preference by 
the mucous patches are the lips, which showed the affection in 38 
cases, the labia majora and minora in 12 cases, and in 11 cases the 
tongue, and in a like number the anus was affected. 

The frequency of the mucous patches on the lips explains how it 
is that the initial lesion of syphilis in women is often found in the 
mouth and in the tonsils. In our experience, we have often had 
occasion to see initial chancre of the tonsils in women, which could 
only with difficulty be detected. 

We sometimes find the presence of secondary symptoms of syphilis 
in a woman, and with careful observation we cannot succeed in finding 
the initial lesion. The pain which accompanies the chancre in the 
ordinary cases is very mild ; the whole trouble is referred to tonsilitis, 
and thus the initial lesion passes unobserved. 

There is no doubt that as long as mucous patches are formed, the 
disease is still directly communicable. Mucous patches usually appear 

2 Ravogli, A. " Syphilitische Plaques." Monatshefte fur Prakt. Dermat., 
1893, p. 78. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 231 

in the first period of the secondary stage, and at times they are the 
only symptom affecting the tonsils or the tongue for months, and re- 
lapse with persistence. Landouzy reported a case of infection of a 
lady through late mucous patches on the tongue of her husband, which 
produced a chancre of the tonsil. The mucous patches had reappeared 
four years after every symptom had completely disappeared. 

We have seen patients affected with mucous patches of the 
tongue five and ten years after the infection, after a long treatment, 
as they claimed, and nearly three years after all other symptoms had 
disappeared. 

These cases, however, are only exceptions, which ought to be 
kept in mind. In a general way mucous patches, after three years, 
appear only rarely. The occurrence of the syphilitic lesions seems 
to be connected with irritations applied on the anatomical regions, and 
possibly to the pathological condition of the blood and lymph vessels 
in this disease. 

The alterations of the vascular system are greatly connected with 
the virulence of syphilis, so much so that where these alterations are 
least, the virulence of contagium is also least. The formation of 
papules is of frequent occurrence, where a mechanical stimulus has 
been applied. In this regard Campana 3 stated that the greater the 
vascular irritability, the clearer is the evidence of the recent date of 
the syphilitic process, and the more contagious is the syphilitic virus. 

Tarnowsky was able clinically and also experimentally to confirm 
the assertion that vascular irritability in syphilitic subjects lasts for a 
certain period of time, and gradually diminishes in proportion to the 
advanced date of syphilis. This observation, although it proves that 
syphilis is virulently contagious in its early period, does not exclude 
the possibility that syphilis may be also contagious in the later stages. 

Gumma has been considered as a non-contagious manifestation; 
it is the result of the localization of the syphilitic virus in the lymphatic 
nodules. It has been repeatedly inoculated without positive results. 
We must, however, consider that gummatous products have under- 
gone caseous and fatty degeneration, which is a condition unfavorable 
to the vitality of the infecting germs of syphilis. The ulceration of 
gummata is the result of the casefication of their elements, and con- 
sequently the gumma is not capable of producing infection under 
ordinary circumstances. 

We have said under the ordinary circumstances, because cases of 
direct infection from gummata have been recorded. Delbanco 4 found 

3 Campana, R. "Duration of Period of Contagion in Syphilis." Third Int. 
Congress of Dermatology. 

4 Delbanco, E. " Zur Infectiositat des Gumma." Monatshefte f. prakt. 
Derm., Bd. 38, No. 12, p. 586. 



2$2 THE MEDICAL ASPECTS 

a married couple, of which the woman had all the symptoms of second- 
ary syphilis, and the man had two ulcerated gummata of the penis, one 
underneath the glans, and another in the deep fold between the penis 
and the scrotum. The man had been infected fourteen years pre- 
viously, and had undergone an insufficient and an irregular treatment. 
Excluding all possibility of reinfection, he concluded that the infection 
of the wife was directly carried from the ulcerated gumma on the 
penis of the husband. 

This is, however, not the only case reported of infection from late 
syphilitic gummata. Similar cases have been referred to by Fournier, 
1875, 5 Landouzy, 1889, 6 Ehlers, 1894, 7 Sack, 1901, 8 and Feulard. 9 
In all these cases reinfection was entirely out of doubt, and the lesion 
which carried the infection was one of the gumma type. The obser- 
vations shake the foundations of the old assertion that gummatous 
productions are no longer capable of conveying infection. Neisser 10 
remarked that all those who have denied the inoculation of syphilitic 
virus from late gummata, speak, nevertheless, of a certain infectious- 
ness of these products. He believed, however, that in the products 
of late syphilis there is some difficulty in inoculation, which is due to 
the anatomical regions, usually attacked and from which the virus 
cannot be easily conveyed. 

In this regard Neumann " maintains the statement of Ricord, that 
products of tertiary syphilis are not capable of inoculation, "nor con- 
veyable as such by heredury. They, however, in consequence of the 
modification or of a peculiar degeneration of the syphilitic virus, con- 
stitute the origin of scrofula. Neuman plainly recognizes that the 
products of tertiary syphilis are not entirely non-infectious, but they 
have much less infectiousness than those of an early secondary syphilis. 
Furthermore, parents affected with tertiary syphilis, or either one of 
them, can have children free from syphilis. Indeed, during the period 
of gummatous formations, the diminution of inoculability in the prod- 
ucts of syphilis, as also of the transmissibility to the offspring, is 
remarkable. 

The degenerated elements of the gummatous products do not 

5 Fournier. Quoted by Feulard. Duration of period of contagion in syphilis. 
Third Int. Cong. Derm. 

6 Landouz}^. " Verhandlungen des 1st. Intern. Dermat. Kongress, 1899." 

7 Ehlers. " Verhandlungen des IV Kongress der Deutsch. Derm. Gesellsh." 
Breslau, 1894. Ref. Von Jadassohn. 

8 Sack. " Verhandlungen der Gesell. Deutsch. Naturforscher und Aerzte 
zu Hamburg." Abt. Derm, und Syph. II. p. 424. 

9 Feulard, H. Third Intern. Congress of Derm. Transactions, edited by 
Pringle, 1898. 

10 Neisser, A. " Ziemsen's Handbook der Spec. Path, und Therap.," p. 681. 

11 Neumann. " Nothnagel's Handbuch." 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 233 

retain, in ordinary circumstances, the infectious qualities, and so also 
the sperma of the persons so affected is no longer capable of trans- 
mitting the disease to the offspring. Neuman referred to cases of 
individuals affected with gummata of the testicle who have been 
capable of generating children free from syphilis. These observations 
have a tendency to show that syphilitic lesions of a gummatous char- 
acter are to be considered more as localized alterations. The trans- 
missibility of syphilis through gummatous productions is not only to 
be doubted, but, as Neuman says, the inoculability must be considered 
as extinct. 

Virchow accepted a physiological distinction between secondary 
and tertiary lesions of syphilis, resting on the inoculability of the first 
and on the non-inoculability of the latter. Hutchinson said that the 
tertiary stage of syphilis begins when the specific virus is dead, so that 
the tertiary lesions are only the result of the vulnerability of the tissues 
induced by the virus. 

Lang maintained that tertiary syphilis is the result of the presence 
of the virus in the tissues, which still remains there although greatly 
modified. Baumler thinks that the syphilitic virus itself by irritating 
the normally reacting tissues, is the cause of the secondary lesions ; 
while in the gummatous productions it is no longer the action of the 
specific poison upon the normal tissues, but in all probability that of an 
irritation produced on tissues already changed by the presence of the 
specific virus, and modified in their reaction by the previous blood 
poisoning. Finger explained the tertiary lesions of syphilis with the 
toxin theory. Gascoyan considered tertiary syphilis merely a conse- 
quence of the disease. 

Experiments have been made in order to clear up so interesting a 
question. Didiers 12 inoculated several healthy men with the blood of 
individuals affected with tertiary syphilis, without positive results. 
Finger made thirty unsuccessful inoculations with the secretion of 
cutaneous and subperiosteal gummata in individuals who had never 
had syphilis. 

The results of the inoculations and the way they had been carried 
out have given reason for doubting to many observers who, resting 
on the basis of the clinical observations, maintained the inoculability 
of syphilis through the gummatous productions. Delbanco claimed 
that : if gumma can inoculate syphilis, it has to contain syphilitic virus. 
Gumma, therefore, still contains living virus. Late syphilitic pro- 
ductions are not different etiologically from the lesions of the sec- 
ondary period. To-day we can say with satisfaction that this ques- 
tion has been settled by positive argument, as the spirochaeta has been 
found in the gummatous productions. 

12 Quoted by Lancereaux. Delbanco, L. C. 



234 THE MEDICAL ASPECTS 

After all the above considerations, we can say that the gumma is 
only rarely inoculated, but we cannot state that gumma is not directly 
inoculable. We have seen cases of ulcerated gummata in married 
men who had never infected their wives, and their children were 
healthy and strong, never having shown any sign whatever of 
syphilis. 

The opinion that the micro-organisms of syphilis are greatly 
diminished in tertiary lues finds great probability, and we think that 
the spirochaetee, on account of the saturated condition of the tissues 
of the system, cannot produce symptoms of a general order, but only 
localized lesions. The views of Campana concerning the caseous de- 
generation of the gumma explains well the difficulty of inoculation, 
because, when the experiments have been made with the serum taken 
from ecthymatous eruptions, the inoculation has taken effect. 

Indeed, Lassar 13 is right when he says that in the question of the 
duration of the period of contagion in syphilis we find ourselves, like 
our predecessors, confined to the observation of cases. Syphilis may 
remain transferable until the morbid process has become extinct, and 
that, given a suitable opportunity and favorable circumstances, the 
disease may again become contagious. It is beyond doubt that con- 
tagion in the late stage of syphilis, if it occurs at all. is very rare. 

Lassar concludes that the experience of the past does not help 
us ; experimentation teaches us quod non; clinical observation yields 
but an evasive answer. I therefore prefer to confess : ignoramus ! 

Feulard, too, expressed himself in this regard that as far as we 
know at present it is impossible to establish fixed rules to define the 
time of the duration of the contagiosity of syphilis. 

We have already expressed our opinion that the papula is the 
lesion which transmits syphilis, and as long as moist papules, are repro- 
duced, syphilis is still contagious. As to the reason of the recurrence 
of the papules, we agree with Feulard, that it must be found in the use 
of tobacco and of strong alcoholic liquors. In the male ward for 
venereal diseases in our hospital, among the patients addicted to the 
use of chewing tobacco, we find obstinate patches on the tongue, lips 
and throat, while they are not so common among the females in 
Ward O. 

That syphilitic gummata in certain peculiar circumstances may 
inoculate syphilis, we find quite possible. In our practice we have 
not yet observed a case of direct transmission of syphilis from a 
gumma, but we rely upon the cases referred to by Delbanco. Sack, and 
others already mentioned. Gumma is a productive specific inflamma- 
tory process caused by syphilitic virus, and the virus in order to pro- 
13 Lassar, O. Third Intern. Congress of Dermatology. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 235 

duce such infiltrated masses must be still alive. Histologically, it is 
difficult to distinguish an initial sclerosis from a gumma ; both are pro- 
ductive granulomata, showing infiltration and proliferation of the con- 
nective tissue. Giant cells which are present in the infiltrating elements 
of the gumma are also found in the initial sclerosis. They are the 
result of the irritation of the decaying cells on the living tissues. The 
same alterations in the tunics of the blood vessels and of the lymph 
vessels are found in the papule as well as in- the gumma. All shows 
that the same virus is the cause of the lesions of the secondary and 
tertiary period. The virus seems to have somewhat lost its infectious- 
ness, either on account of the diminished quantity of the germs, as 
Jadassohn thought, or on account of being damaged by the process 
of hyaline or caseous degeneration, to which the infiltrating elements 
of the gumma are subject. 

For this reason the direct transmission of syphilis through gum- 
mata is only an exception, and we can say that in ordinary circum- 
stances, after three years when mucous patches do not recur, the danger 
of the direct inoculation is nearly passed. 

This statement might suggest that after three years from the 
infection a man can get married without fear of infecting his wife. 

Although there is some truth in it as to that, which we call direct 
transmission of syphilis, we must consider another danger for the 
woman, which is the indirect transmission of syphilis from the fetus, 
known as syphilis by conception. 

SYPHILIS BY CONCEPTION 

A syphilitic husband, by seminal infection, generates a syphilitic 
fetus, the mother has never been infected, but at the end of the 
pregnancy she shows symptoms of syphilis. She does not show any 
direct transmission of the disease by inoculation, but the infection is 
effected through the uterine circulation from the syphilitic fetus. 

In this case the woman is infected by the poison which the ovum 
has received in the fecundation, which has multiplied and developed 
with its growth, so as to infect the whole child, and through the nutri- 
tive changes of the fetal life the poison is conveyed into the system 
of the mother. 

Fournier, in his beautiful work, " Syphilis and Marriage," calls 
attention to this mode of infection, which by many authors has been 
left without consideration, and by others has not even been believed. 

We must confess that we were in the class of the non-believers 
in this mode of infection. 

In syphilological experience, we quite often think a woman 
married to a syphilitic man to be perfectly free from syphilis, and yet 



236 THE MEDICAL ASPECTS 

we will find later on that she is really infected. Colles law is a proof 
for this assertion. If the mother is immune from taking ulcers by 
her own syphilitic child, this is the result of her being affected with 
syphilis, which renders her immunized. Any other healthy wet nurse 
giving her breast to a syphilitic child will surely be infected with 
chancre of the breast, and consequent syphilitic symptoms, while the 
mother never shows any chancre, and is apparently not affected. Cas- 
pary 14 referred to a very striking case on the subject of healthy 
mothers of syphilitic children, where he showed that the immunity 
of the mother, giving birth to a syphilitic child, is produced by the 
presence of syphilitic infection. 

It is of great interest for us to briefly refer to the case of Cas- 
pary : A married man, in 1872, acquired syphilis, during the period 
of acute symptoms he abstained from sexual relations with his wife, 
but when the symptoms subsided he resumed the coitus. The woman 
never showed any manifestation of syphilis. In October, 1874, she 
became pregnant. In March, 1875, sne suffered uterine hemorrhages, 
and a few weeks later aborted. The examination revealed a gum- 
matous infiltration of the maternal portion of the placenta. The 
woman recovered, and never showed a symptom of syphilis. Caspary, 
in order to satisfy himself whether the woman was the subject of 
latent syphilis, persuaded her to be inoculated with the secretion of an 
active syphilitic lesion. She was inoculated in four places with the 
secretion of mucous patches, from a man suffering with the eruptive 
stage of early syphilis, who had not yet received any treatment. In 
every case the inoculation showed negative results. This proved con- 
clusively that she was affected with latent syphilis, which immunized 
her from the action of the virus. Consequently the Colles law will 
find in many cases its explanation in the latency of syphilis. There 
occurred in our practice a case of a lady who became infected from 
her offspring in utero, which evidently showed the truth of syphilis 
by conception. In November, 1890, a gentleman called on us for a 
hard chancre in the sulco balano preputiale, with beginning adenop- 
athy on both inguinal regions. In January, 1891, he showed marked 
maculo-papular syphilide of the whole body. He began treatment, 
but he only carried it out irregularly and insufficiently. We did not see 
him for a long time, as he claimed to have always been well. In 1894 
he married a young lady in splendid health. In 1895 she gave birth 
to a child rather weak and delicate. From what we could learn, the 
child never showed any syphilitic symptoms. In 1897, towards the 
end of her second pregnancy, she began to feel bad, was feverish, and 

14 Caspary. " Ueber gesunde Mutter hereditar-syphilitischer Kinder." Vier- 
teljahreschrift fiir Dermatologie. 1875, p. 437. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



237 



just after she was delivered she was covered with an eruption, and, as 
she said her genitals were covered with ulcers. We were called to 
see her some time after, and we found her suffering with papular 
syphilides, mucous patches of the mouth and tonsils, mucous patches 
of the small labia, and general adenopathy. The babe was weak, but 
not badly nourished, had a swelling of the third phalanges of two 
fingers, characteristic syphilitic dactylitis. 

The first child, at that time two years old, was a small, delicate 
little girl, of bright intelligence, who showed only a few hard, enlarged 
lymphatic glands of the groins and of the cervical region, but with this 
exception, nobody could say that she was syphilitic. 

The second babe, five months old, who had transmitted the infec- 
tion to her mother, had no other symptoms than syphilitic dactylitis, 
which belongs to the tertiary manifestations of syphilis. This con- 
firms our views that syphilitic virus in the secondary or tertiary stage 
is always the same virus, and that when communicated to a healthy 
person is liable to bring about the whole evolution of syphilis. 

In this case the man had been infected four years before his 
marriage, and he had undergone an irregular and insufficient treat- 
ment. He had no active symptoms, so he could not infect his wife. 
The first child was apparently well, and has never shown patent 
symptoms of syphilis. The second child had infected the mother dur- 
ing the time of pregnancy, and it was affected with symptoms of late 
syphilitic diathesis at its birth. 

This case has been for us a clear case of syphilitic infection by 
conception, and one in which the syphilitic child could infect its 
mother through the utero-placentary circulation. In these cases the 
evolution of syphilis is different from the ordinary cases in its origin 
and in its development. The woman was in good health, she never 
showed an initial lesion or any progressive adenopathy ; syphilis breaks 
out at once, accompanied with symptoms of acute general infection. 

Boulengier 15 has likewise found that a woman married to a 
syphilitic man who no longer shows symptoms of the disease, when she 
becomes pregnant may be infected by her own syphilitic child. 
Diday 16 found seven cases where syphilis had been transmitted by 
conception, and all seven children were deeply affected with syphilis. 

There is no doubt that when the mother has not been infected by 
her syphilitic husband, she will be infected by her syphilitic child, in 
the same way that a syphilitic mother will transmit syphilis to her 
developing child. 

15 Boulengier. "La Syphilis par conception." Presse Medicate Beige, 1894. 
No. 37. 

16 Diday, P. " Le peril venerien dans les families." Paris, 1881. p. 196. 



238 THE MEDICAL ASPECTS 

The sperma contains the syphilitic germ, and at the act of fecunda- 
tion generates a syphilitic child through which the mother is infected. 
The woman so infected can either show symptoms of a severe case of 
syphilis, or she can have very mild and scarcely perceptible symptoms. 

It is true that in the woman it is sometimes very difficult to find 
the primary lesion which may be concealed. But in our case, the hus- 
band had not shown symptoms of syphilis for years, and her affection 
had begun to show at the end of her second pregnancy. The only 
explanation of the infection lays in the direct entrance of the virus 
through the utero-placentary circulation. 

The explanation and the proof of this statement is found in the 
following chapter. 

GERMINATIVE INFECTION 

The clinical observations in syphilis had given rise to the idea 
of a germinative infection long before the existence of the idea of a 
living contagium, according to the modern understanding". It is a 
fact that a cell containing a parasite may undergo its biological prog- 
ress, develop and live, containing the parasite in itself. 

The old statement that a cell containing a parasite is not subject 
to development has already been denied by the discovery of Pasteur 
upon the possibility of the spermatic infection in the disease of the silk 
worm, known as pebrine. He proved that the organisms of pebrine 
enter the eggs, and the cells of the sperma, and these cells containing 
the germ of the parasite are not destroyed, but retain the faculty of 
fecundation and the insect is again generated. 

Maffucci 17 succeeded in inoculating eggs of hens with tuber- 
culosis, showing conclusively that the bacillus tuberculosis does not 
prevent the development of the egg. The bacillus is taken up by 
the embryo and is embodied in the same, and after the little- chicken 
has been hatched, after nearly twenty days of incubation, tuberculosis 
breaks out. Maffucci, moreover, succeeded in finding tubercle bacilli 
in the albumen, and also in the embryo in the form of small nodules, 
which shows that the tubercle bacilli can undergo involution, taking 
a latent condition. 

This affords us the explanation for the latency in hereditary in- 
fectious diseases. We can now understand how it is possible that 
the tubercle bacilli remain dormant in the embryo, probably in the 
condition of larvae, or as a simple potentiality, and after the birth of the 
individual, sooner or later are capable of proliferation, starting a new 
tubercular formation. 

17 Maffucci. Centralblatt filr Bacteriologie und Parasitenkunde. 1889. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 239 

The chronicity of tuberculosis, the slow development of the bacilli, 
is the explanation of their development only some years after birth. 
Johne, Bang, Leichtenstern, Gaertner, and others have succeeded in 
proving the heredity of tuberculosis by means of the inoculation of 
the eggs of birds. 

If that happens in tuberculosis, we do not find any objection in 
admitting the same possibility with reference to syphilitic infection. 
In syphilis the micro-organism, a spirillum, has been recently demon- 
strated, and it has been obtained to inoculate lower animals, but yet 
we will not be able to repeat the experiments as for tuberculosis. In 
syphilis we must follow so far the criterion of analogy and from that 
come to conclusions. 

Syphilitic virus is so transmitted from the father to the offspring 
in the sperma, and the fetus is thus generated with syphilis. In some 
cases the syphilitic virus remains latent in the system without inter- 
fering with the development of the fetus and without infecting the 
mother. The babe is born in good health, shows no signs of infec- 
tion, but after some time the lymphatic glands gradually become hard 
and enlarged, and syphilitic symptoms appear. 

In the case above referred to we had a healthy mother, who had 
given birth to an apparently healthy child, but the father was syphilitic. 
The mother did not have any specific trouble ; the child is now a little 
girl, in delicate health ; she. has never shown symptoms of syphilis, 
but her lymphatic glands are slightly enlarged. The second child, 
who was born with a syphilitic dactylitis, was the one which infected 
the mother. This child, in the conditions of a fetus, had syphilis in 
fact, and it was the cause of infection of the mother. Syphilis, like 
tuberculosis, may remain latent in the depths of the system for years 
without showing its presence at all, and then after some years a gum- 
matous or an ulcerative process shows as a new and difficult problem 
for the physician. 

In many cases syphilis kills the fetus in utero,, on account of the 
cachexia which it produces in its system, without showing any appar- 
ent syphilitic lesions. In several cases of miscarriages, and of chil- 
dren who died a few days after birth, and who were delivered in the 
venereal ward from syphilitic women, the post-mortem was unable to 
reveal any apparent symptoms of syphilis. In many cases the skin 
was found normal, no ulcerations, the spleen normal, and the epiphyses, 
which are often found affected with a chronic inflammatory process in 
syphilitic children, w T ere normal. 

The cause of death seems to have been in the lungs, in the form 
of pneumonia. The lungs were red, hard and infiltrated, and when 
cut a quantity of bloody serum was oozing out, which was in the 



240 THE MEDICAL ASPECTS 

pulmonary cells. The fetus in these cases had met death more on 
account of a general cachectic condition than on account of a defined 
syphilitic manifestation. 

The infection of the fetus can be carried through the sperma as 
well as through the placenta. The sperma of a man who is still under 
the poisoning influence of syphilis carries the infection to the egg, and 
although the woman is entirely free from syphilis, the fetus receives 
the infection. The syphilitic virus is developed in the system of the 
fetus, and through the exchanges of nutrition between the fetus and 
the placenta carries the syphilitic infection to the mother. 

It may also happen that syphilitic virus remains latent in the fetal 
system; in this case the mother will receive no infection, although late 
in life the offspring may show symptoms of syphilis. The spermatic 
infection is therefore a fact which cannot be denied, and it remains as 
a menace for a healthy mother with a syphilitic husband. This is a 
fact to be remembered by anyone who thinks that syphilis cannot be 
communicated except from an ulcerative process, and that when no 
sore exists there is no danger of transmission of syphilis. 

Nobody can give any assurance on the prognosis of syphilis, and 
not rarely, on account of causes inherent in the system of the woman 
or on account of neglected treatment, there may arise cases of malig- 
nant syphilis, or at least of syphilis with deep and severe destructive 
lesions. 

In consequence, a man who has been infected with syphilis must 
not be contented with the two years so often established as the end of 
his quarantine, but must follow the advice of the physician and he will 
receive his clean patent when the physician will recognize him as 
scientifically cured. It is not merely a question of two years, but as 
long as suspicious symptoms of secondary infection are still returning, 
the patient cannot be advised to enter married life. He would be a 
continuous menace to the health of his wife and of his family. 



CONGENITAL AND HEREDITARY SYPHILIS 

From the above considerations we have seen that syphilis from 
the father is transmitted to the offspring as a sad and miserable in- 
heritance. If a man who has had syphilis has not had sufficient treat- 
ment or if sufficient time has not elapsed since infection and he enters 
married life before the virulence of syphilis is extinct, he is not only 
dangerous to his wife, but also to his family. Syphilis will be trans- 
mitted to his offspring by heredity. 

The question of congenital and hereditary syphilis is not yet defi- 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



241 



nitely settled. Solger, 18 following the ideas of Matzenhauer and of 
F. Martius, would limit the word hereditary to all cases of infantile 
syphilis where the resulting symptoms are due to the union of the 
infection in the semen and in the egg. For all other cases he would 
keep the word congenital. He thinks that in syphilis there is not a 
true inheritance, but only an intra-uterine transmission of syphilis to 
the fetus. 

We see quite clearly the distinction between congenital 'and 
hereditary syphilis. When a babe comes into the world with syphilitic 
cachexia, or a few days after birth shows syphilitic manifestations, 
this is without doubt a congenital syphilis. In this case syphilis has 
been transmitted to the offspring as an intra-uterine infection just as 
any other infectious disease. When, however, a babe from syphilitic 
parents is born somewhat weak, or sufficiently healthy, and later on 
in life begins to show syphilitic manifestations, he has hereditary 
syphilis. In this case syphilis has not been transmitted as an infectious 
disease, but the germ of syphilis has been transmitted as a potentiality 
which will show later on in the form of syphilitic symptoms or rather 
as parasyphilitic affections. It is clear that the offspring in these 
cases has inherited syphilis. 

The transmission of syphilis from the paternal side only has been 
the subject of great controversy, and it has diminished in its interest 
from the observation of healthy families raised by men who had 
formerly been affected with syphilis. Cullerier, 19 Notta, 20 Charrier, 21 
Durac, 22 Mireur, 23 Oewre, 24 Sturgis 25 have already brought out ob- 
servations, showing that paternal heredity is only of rare occurrence, 
and that children of a syphilitic father, who have not infected their 
mother, usually remain free from syphilis. 

Matzenhauer in a paper read at a meeting of the Society of 
Physicians of Vienna on February 6, 1903, on the heredity of syphilis, 
expressed doubt as to the existence of the paternal heredity alone, 
just for the reason that syphilis is communicable almost at any period. 

18 Solger, F. B. " Hereditar oder Kongenital ? Ein Beitrag zur Frage von 
der Vererbung der Syphilis." Centralblatt. VII Jahrg., Heft 9, 1904. Ref. 

-Monatshefte f. prakt. Derm., Bd. 39. 

19 Cullerier. " De l'heredite de la Syphilis." Paris, 1851. 

20 Notta. " Memoire sur l'heredite de la syphilis." Arch. Gen. de Medicine, 
i860. 

21 Charrier. "De l'heredite Syphilitique." Arch. Gen. de Med., 1862. 

22 Durac, J. E. " De l'heredite de la syphilis." These de Montpellier, 1866. 

23 Mireur, H. " Essai sur l'Heredite de la Syphilis," 1867. 

24 Oewre. " Sur l'etiologie de la syphilis hereditaire." Ann. de Derm, et de 
Syphil. 

25 Sturgis. " Sur l'etiologie de la Syphilis hereditaire." Ref. Ann. de Derm. 
et de Syphil. 



242 THE MEDICAL ASPECTS 

He went on further to deny all direct transmission from the father 
to the offspring, as he considered hereditary syphilis to be only an 
mtra-uterine infection through the infected mother by the placentary 
circulation. In his opinion a healthy woman cannot have a syphilitic 
child. Riehl also considered the statement that tertiary lues, especially 
at the gummatous period, is not communicable as incorrect, and he 
thought it improbable that a man, who has syphilis with which to 
generate a syphilitic child would not communicate the disease to his 
wife. 

The dogmatic assertion of Ricord, that tertiary syphilis is not 
communicable by contact or by heredity, has been upset by the obser- 
vations of Landouzy, which have been confirmed by Fournier and 
have been later accepted by Arnozan, Hardy, Petrini De Galatz and 
Leloir. 

Mauriac considered a man who shows subcutaneous nodes just 
as suspicious as the one who has papules. He is saturated with 
syphilitic virus just as much as any other with papular or macular 
eruption. 

The question which is not clear for us is how a syphilitic father 
generates syphilitic offspring, which is killed in utero by syphilis, or 
shows deep manifestations of syphilis at its birth, and the mother is 
not infected. To us, it is the repetition of that which we have said 
already in reference to Colles law, that the healthy condition of the 
mother is only ephemeral. If the mucous patches on the mouth of 
her babe cannot inoculate the mother, that is a clear sign that she 
is immunized, and she cannot be inoculated with any other syphilitic 
virus. 

There is no doubt at all that syphilis is transmitted to the offspring 
fry the father through the semen in the act of fecundation. The ques- 
tionable point for us is whether the mother remains healthy. 

Observations taken from Ricord, Bassereau, Ruge, Hutchinson, 
Fournier and many others have all referred to cases of families where 
paternal heredity alone has caused infected children. Hutchinson 26 
has clearly spoken in favor of paternal heredity when he wrote, " I 
am firmly of the opinion that in a large majority of instances in 
English practice, inheritance of syphilis is from the father, the mother 
having never suffered before conception." 

In so debated a question, with such different opinions, we must 
search for some arguments from clinical experience. In our practice 
we have treated many patients affected with syphilis for a period of 
several years; they have recovered and have married. At present 
they have several children, all healthy, intelligent, bright, and nobody 

26 Hutchinson, J. Medical Times and Gazette, 1876, quoted by Fournier. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 243 

would suspect for a moment that the father had undergone a rather 
severe case of syphilis. 

Fournier reported 87 cases of syphilitic men who have married, 
and have never communicated syphilis to their wives, and have had a 
total of 156 children absolutely healthy. Of these 87 men, 20 only 
had married before the fourth year after the infection, 11 after the 
fifth year, 10 after the sixth, 4 after the seventh, 8 after the eighth 
year, 6 after the ninth year, 2 after the tenth year, 4 after the eleventh 
year, 2 after the twelfth year, 1 after the thirteenth, 1 after the 
fourteenth and 1 after the fifteenth year. All these men have married 
after a long treatment, and after a period when the contagiousness 
and the transmission power of syphilis can be considered as extinct. 

It must not be believed that all these cases have never again 
shown specific symptoms. Thirty-five of them have had syphilitic 
lesions after marriage, and also serious functional troubles, sufficient 
in some cases to cause severe disease and death. Yet they have never 
communicated the disease to their wives, nor have their children 
shown symptoms of syphilis. 

In this regard w T e cannot forget a very wise remark of our teacher, 
Sigmund von Ilanor, that we must not content ourselves with the 
observation of the children in their first years of life, the observation 
has to be continued during their entire lifetime, and very likely a 
moment will come when troubles appear which are to be connected 
with a specific taint. 

In our practice we had occasion to give treatment to a gentleman 
for a case of late syphilis, while he was married and already had 
children, who were perfectly healthy. He had married nine years 
after the infection, and it was several years since he had seen any sign 
of the disease. His children are now grown and have always been well. 
One young man was brought to us with a peculiar eruption on the 
soles of his feet, which was considered to be the result of corns. 
Local applications of emplastrum hydrargyri, and large doses of 
potassii iodidi cured the so-called corns. 

This shows that hereditary syphilis has to be divided into early 
hereditary syphilis and late hereditary syphilis. 

That a father still under the influence of an old syphilis may 
generate a child with the latent germ of syphilis, without communi- 
cating the disease to his wife, is a case of common occurrence. But 
when the father has syphilis so active as to generate a child which is 
killed in utero by syphilis, or comes into the world with congenital 
syphilis, we find it nearly impossible for the mother to have remained 
perfectly healthy. The quantity of the syphilitic virus, the time elaps- 
ing from the infection of the father or of both parents, the intensity 



244 THE MEDICAL ASPECTS 

of the virus, have a great influence on the developing organism of 
the fetus. 

In fact, when the parents have had a recent syphilitic infection ; 
and they have had no treatment, or only an insufficient one, the babe 
will be killed in utero. Tarnowski 2T collected very important sta- 
tistics of 25 syphilitic families, in which there occurred 155 preg- 
nancies with the result of 57 still births and 98 living children. In 
another work Tarnowski 28 brings statistics of 30 other families, all 
of the Slavish race. In 29 of them lues came from the man, and in 
24 the wife remained free from syphilis. Amongst 26 families there 
occurred 169 pregnancies of the first generation with the result of 
thirty-five per cent, abortions, and sixty-five per cent, living children. 

Kassowitz 29 brings statistics of 43 families, in which the father 
was syphilitic and the mother showed no signs of the disease. Mews, 
Hecker, Fournier, all have cases of families showing the heredity of 
syphilis from the paternal side only, where the mother has remained 
free from syphilis. 

In our experience we have had occasion to treat for a long time 
a large number of young men for syphilis in the secondary period. 
They have married when declared cured, and no taint of syphilis has 
been seen on their children. 

We have often had occasion to be consulted by young married 
couples, complaining that they had had the misfortune of several 
children born dead. We have found the husband, who had suffered 
syphilis, had received a few weeks' treatment, then after a year or so, 
having seen no more trouble, he had married. The wife had always 
been well, only she has been subject to miscarriage. In our next ex- 
perience the healthy condition of the wife is only apparent, and sooner 
or later she will show symptoms of syphilis. 

In a syphilitic family, where the wife, in spite of several mis- 
carriages, had remained free from syphilis, having always enjoyed 
good health, at the age of fifty, many years after, she showed an 
eruption of multiple ulcerated gummata on her left knee, which were 
witness that she was not absolutely free from syphilis. 

We do not dispute the paternal origin of syphilis ; the only point 
on which we do not agree is that of the wife's remaining absolutely 
free from syphilis after having had syphilitic children. We are posi- 
tive that if all those women married to syphilitic men, who have given 

27 Tarnowski, B. " Descendance des Heredo-Syphilitiques" Compt. Rendus 
Congres. Intern. 1900, p. 307. 

28 Tarnowski, B. " Ueber die Syphilitische Familie und ihre Nachkom- 
menschaft." St. Petersburg. 

29 Kassowitz. " Die Vererbung der Syphilis." Wien, 1876. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



245 



birth to syphilitic children and have been declared absolutely free 
from syphilis, could have been seen later by the distinguished authors, 
they would have changed the word absolutely to apparently free. In 
our City Hospital, in M ward, only women of good moral character, 
belonging to g-ood families, are accepted, and one-third of those who 
come there to be treated for leg ulcers are affected with ulcerated 
syphilitic gummata of the legs. It is understood that there is no 
history of syphilis to be obtained ; sometimes there may be the history 
of a couple of miscarriages in the beginning of the married life. In 
all, they have always been in good health. 

We believe that when the syphilitic infection of spermatic origin 
is so active as to generate a syphilitic fetus which is killed in utero, 
the mother cannot remain absolutely free, but she will be only appar- 
ently free from syphilis. 

When, however, a man who has married several years after the 
infection and has been sufficiently treated, transmits through the 
sperma the syphilitic germ to the ova, then the germ will remain 
latent and inactive. In this case the babe is born well. The mother 
is free from syphilis. The germ of syphilis, however, transmitted by 
paternal heredity will develop in the organism of the babe and after 
several months, or even years, will show in the form of late hereditary 
syphilis. 

This will form the subject of another interesting chapter on the 
influence of paternal heredity on the production of various morbid 
conditions, of degenerations and physical and moral anomalies, which 
are the sad result of syphilitic inheritance. 

The syphilitic germ is introduced into the ovum from paternal 
syphilis. Its hereditary influence is manifest in various forms and 
degrees of severity. If a man affected with syphilis contracts mar- 
riage before it is extinct, admitting that his wife is lucky enough to 
escape contagion, less than one out. of every four of his children will 
survive. 

Paternal heredity has a great influence on the fetus, but when 
the mother is also infected, then the maternal and paternal heredity 
has a much more deleterious action. 

MATERNAL HEREDITY 

The syphilitic infection is brought to the developing fetus through 
the placentary filter from the maternal side. Observations show that 
the influence of maternal syphilis is much more potent and intense 
than that of the father, and also persists for a longer time. 

The infection takes place through the placenta, which has been 
considered an undeniable dogma and an established fact. New works. 



246 THE MEDICAL ASPECTS 

however, by Wolff and Gartner have shown that the infection through 
the placenta is not so easily understood. Syphilitic infection through 
the placenta happens, and cannot be denied, although there is some 
doubt in regard to tuberculosis. 

The normal placenta is a perfect filter and does not allow the 
passage of strange bodies, capable of multiplying themselves, through 
it. The micro-organisms, however, coming into contact with the 
placenta, are capable of producing disease of this organ, such as 
emboli, hemorrhages, necrosis of the endothelium, and through this' 
they can effect an entrance through the walls of the placenta. It is 
through this morbid condition induced by the germs of the disease 
that the placentary filter may become permeable, and the spreading 
of the disease to the developing fetus be made possible. 

In this way only can we explain how it is that syphilitic women 
can give birth to healthy children. Indeed, we often find the placenta 
affected with gummatous productions and the child escaping every 
trace of infection. 

This happens especially in cases of tertiary syphilis, where the 
syphilitic virus is modified in the system and has lost its contagious 
properties. In the late period of syphilis the placenta seems to retain 
the infectious toxins of syphilis, leaving the offspring free from any 
trace of the disease. 

The peculiar anatomical structure of the placenta, and its physio- 
logical functions, are such as explain what influence it has in prevent- 
ing germs from passing through it, and thus explain many cases in 
syphilology which are still surrounded with darkness. 

Zeissl 30 referred to cases where the infection has shown itself in 
an alternating way, so that one child was syphilitic and the next was 
healthy, and so on. 

The placenta always offers pathological conditions in case of a 
syphilitic fetus. It is often smaller, badly developed, flabby, easily 
broken. The surface of the placenta which is adherent to the uterine 
surface, shows, at times, spots of hepatization and calcareous incrus- 
tations. 

Often the placenta is adherent to the surface of the uterus and 
it requires the hand of the surgeon to detach it. Virchow has found 
tumors in the placenta which were nothing but gummatous productions. 
In these cases the fetus either dies in utero on account of the diseased 
placenta, or if the placenta is only partially affected, the fetus suffers 
no evil effect and remains free from syphilitic infection. 

In reference to this matter we had occasion to deliver a lady for 
adherent placenta. The history of the family is not known, as it has 
so Zeissl, H. " Lehrbuch der Syphilis," Wien, 1871. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 247 

always been concealed. Some nine years previously we had been 
called in consultation by the family physician to see this lady. She 
was suffering with an extensive and destructive ulcer of both legs. 
It was a case of multiple ulcerated gummata. The general health of 
the lady was rather good, although she was suffering with pains 
resulting from productive periostitis of the tibiae. Antisyphilitic mixed 
treatment was ordered, which was followed, under the direction of 
her family physician. 

For more than two years we had heard nothing more of the pa- 
tient, when we were called by a midwife to remove the placenta in 
this same patient. She had given birth to a living child at full term, 
well developed and healthy. The placenta remained in utero and 
could not be removed. It was adherent to the whole surface of the 
uterine parietes, and it was necessary to detach it by the hand, and 
then scrape the endometrium with the dull curette and pack with iodo- 
form gauze. 

The placenta was inconsistent, flabby, easily broken, and spotted 
with foci of infiltration, yellow in color, round in shape, which were 
adherent to the decidua. The babe, as stated, was healthy, weighing 
eight and one-half pounds, well developed, showing no trace of syphilis. 

Some years after we were called again by the same midwife to 
help the same patient, who had an adherent placenta. With some 
difficulty the placenta was detached and removed, and -it showed the 
same conditions of infiltration in foci as in the previous case. The 
babe, healthy and well developed, had no trace of syphilis. 

The babe which had been previously attended was a little girl, 
at this time four years old, enjoying good health. She had never 
shown signs of syphilis and had never been sick one day. From the 
macroscopic and microscopic examinations of the placenta it w r as plain 
that those circumscribed foci of infiltration in the placenta were due 
to a gummatous process between the decidua and the placenta, causing 
infiltration and adhesions of the latter. The process, however, re- 
mained limited to the placenta itself, which did not allow the infection 
to be carried to the fetus. 

We have already quoted what Sigmund used to say, that when a 
babe is born of syphilitic parents, although apparently well, we must 
not content ourselves with its actual condition, but must follow it in 
all the periods of its life. Sooner or later syphilis will show its 
existence in that organism, although it has appeared perfectly free 
until then. These views, however, according to our own experience, 
are too pessimistic, and indeed tertiary syphilis at a late period seldom 
affects the fetus by placentary infection, especially if the syphilitic 
mother has undergone a good antisyphilitic treatment. In the second- 



248 THE MEDICAL ASPECTS 

ary period, when syphilis is at its acute stage, like any other acute 
infectious disease, it passes through the placenta and infects the de- 
veloping fetus, which in most cases dies in utero. 

Ricord 31 speaking from his experience says that women affected 
with recent syphilis seldom have a child at full term, and that in the 
beginning of the eighth month they usually have a miscarriage. 

Barnes thinks, that syphilis produces a peculiar inflammatory 
condition of the mucous membrane of the uterus, which forms the 
decidua, and consequently it is spread to the placenta, from which the 
fetus receives its nourishment, thus causing the abortion. 

The fetus of a syphilitic mother or of both syphilitic parents, when 
dead in utero, is brought out with the skin macerated by the amniotic 
fluid. The epidermis is detached in large strips, the amniotic fluid has 
a foul smell and a turbid and foul appearance. When the fetus dies be- 
fore the fourth month of utero-gestation, no characteristic pathological 
alterations are, as a rule, to be found. After the fifth month the spleen is 
usually found increased and hypertrophic, maintaining its regular shape. 
In a syphilitic fetus dead after the fifth month of utero-gestation, there 
is often found a peculiar osteochondritis, to w T hich George Wegner 3 ' 2 
was the first to call the attention of the pathologists. In the normal 
line between the diaphysis and the epiphysis of the fetal bone, exists 
a whitish layer, where the normal calcification of the cartilage takes 
place. In syphilitic babies this layer is larger, dry, hard, and instead 
of being a straight line shows indentations. This peculiar osteo- 
chondritis is the cause of a kind of sclerotic density mostly in the 
long bones of syphilitic children. 

From our personal experience we have found that this condition 
of the bones is not so constant as is generally believed. In ten post- 
mortems of fetus and infants born of syphilitic mothers in the venereal 
ward of the City Hospital, which have been born dead or have died a 
few hours after birth, we have found this condition of osteochondritis 
in the epiphyses of the bones in two cases only. 

Tke thymus is also often affected in the body of a fetus killed by 
congenital syphilis. 

When the mother is syphilitic in the secondary stage we have 
never seen a child escape infection. It is a question of degree, but 
everv child if it escapes death in utero, comes to light sometimes ap- 
parently free from syphilitic symptoms, but a few days or a few weeks 
afterwards the babe will show either symptoms of syphilis or of syphi- 
litic cachexia. 

3-1 Ricord. " Lettres sur la Syphilis." Paris. 1852. 
32 Werner. G. Virchow's Archives, 1870. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 249 

To the function of the placenta we can refer the case of twins of 
which one was syphilitic, and the other was free from infection. 

A case of this kind was reported some years ago by Jonathan 
Hutchinson. 

The illustration shows twins thirty days old, of which the 
first born showed syphilis pustulo-crustacea scattered on the auricula, 
chest and scalp. Its appearance is emaciated, the skin lacks panniculus 
adiposus, the face looks old. The other babe is much brighter, well 
nourished, and has never shown any symptoms of syphilis. 

The father shows remnants of old periostitis of both tibiae, with 
resulting induration and roughness of the periosteum. Deep scars of 
healed-up gummata are found in several regions of his body. He has 
no knowledge of infection. 

The mother came to our office in February, 1897, affected with 
syphilis ulcerosa of the tongue, a deep irregular ulcer on the left side 
from gumma. She was then in the eighth month of gestation. At 
the end of March she gave birth to the twins here represented, both 
of the male sex, one weighing nearly eight pounds, the other less than 
seven pounds. Both were weak and poorly nourished. The patient 
had been attended by a midwife, so we had no opportunity of seeing 
the placentae. 

The second born, who was somewhat better nourished, soon 
began to improve, and in a few days was looking healthy and has never 
been sick since. The first born, who was already weaker and poorly 
nourished, was affected with a stubborn diarrhea for several days, 
and took on that senile appearance peculiar to syphilitic children. 
With small repeated doses of calomel the diarrhea subsided, and the 
child grew better. A pustular syphilitic eruption appeared on his body. 
The child breathed with difficulty, and died with pneumonia in the 
early part of September. The other babe is now a big boy, enjoys 
good health, and has never shown any syphilitic symptoms. 

It seems quite clear in the case above referred to, that the syphi- 
litic infection has affected one of the twins and has spared the other. 
We can explain so interesting a fact only by the functions of the 
placentary filter, which has prevented the passage of the virus to one 
of the fetuses. In this case we cannot accept as an explanation the 
wearing out of the virus, as maintained by Diday. The woman was 
surely syphilitic, and both fetuses ought to have been infected alike, 
but one showed hereditary syphilis, while the other has so far appeared 
to be free from hereditary infection. 

The influence of the mother in transmitting the infection to the 
offspring is much more persistent, and much more pronounced, than 






250 THE MEDICAL ASPECTS 



that of the father ; when both parents are affected the fetus will very 
rarely escape syphilis entirely. 

We have already seen that a man who was once affected with 
syphilis, but has undergone a good vigorous treatment, when married 
after a certain period of time, if his wife has not been infected, will 
have healthy children, probably without any syphilitic taint. When 
the woman is infected, then the transmission of syphilis by hereditary 
infection is certain, and much more persistent. 

MATERNAL HEREDITY ALONE 

It is interesting to bring this subject under consideration in order 
to show that the syphilitic infection is more stubborn and persistent 
when the mother is infected than in the case where the father alone 
is syphilitic. In the first years of our practice we were consulted by 
a young lady, then twenty years old. She was very anemic, and was 
suffering with anomalous affections of different kinds, neuralgia, 
catarrh of nose and throat, headache, rheumatism ; for nearly two 
years she was not able to obtain any benefit from the remedies ad- 
ministered. Some enlargement of the cervical glands caused us to 
suspect the presence of lues, and on questioning her she said that she 
had hemorrhoids. On examining the so-called hemorrhoids, we found 
them to be a mucous patch of the size of a dime, concealed in the 
folds of the anus. 

There was no more doubt about the girl's being syphilitic and 
she was immediately subjected to treatment with intramuscular in- 
jections of a one per cent, sublimate solution, and a tonic internal 
medication. 

The young lady improved very rapidly, and after ten or twelve 
injections she was so much better that she considered herself entirely 
well and gave up the treatment entirely. 

Nearly two years afterwards she was married to a healthy young 
man, and as we had charge of them as the family physician, we can 
vouch that he had never had syphilis. From this marriage the lady 
became pregnant, and at the seventh month of utero-gestation she 
brought to light a dead fetus, half decomposed in a foul amniotic 
fluid. Each year the same thing happened until she had nine dead 
children. 

The last children were born at full term, but after a few days they 
began to show unmistakable signs of hereditary syphilis. The hus- 
band has always remained well, and the lady has never shown any 
more symptoms of syphilis, enjoying splendid health. 

The knowledge of the cause of the unfortunate end of all her 
children has remained with us, and has never been mentioned even 



Plate XII 





I 







Twin Boys from Syphilitic Parents 

One infected and the other healthv 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



251 



to the lady. We had often advised her to undergo treatment, but she 
never heeded the advice. She has often changed physicians, so once 
in a while we lost sight of her. 

Some years after she came back, crying about a horrible mis- 
fortune, that she was enceinte again. We promised her that if she 
would take a four months' treatment she would give birth to a healthy 
child. She consented and immediately began treatment, which con- 
sisted of inunctions with mercurial ointment one and one-fourth 
drams, every other night, and from 90 to 120 drops of a saturated 
solution of potassium iodide daily. 

The treatment was stopped for a few days, when symptoms of 
mercurial stomatitis began to appear, and as soon as they were better 
the treatment was resumed again. She kept on with her treatment 
for nearly five months. Then it was stopped. 

This time she gave birth to a healthy child, who has always been 
in splendid health. The process of ossification of the fontanellse has 
been regular, the teeth are normal, and he has been the blessing of 
that family. 

When he was three years of age he had spasms, for which they 
sent for us. It was an evident case of Jacksonian epilepsy, recalling 
the syphilitic taint from his mother. With a treatment of potassium 
iodid the epileptic attacks diminished and finally disappeared. He is 
now a grown boy, well nourished, strong, intelligent, has never been 
sick since, and appears to be the picture of health. 

This case has been referred to in all its details, for the reason 
that a case of syphilis in the mother alone is not commonly observed. 
It shows how the infection passes with more certainty and with more 
persistence from the mother to the fetus, and how the treatment is 
capable of saving the offspring from infection. 

STERILITY FROM SYPHILIS 

Ricord said that women with an old syphilis are usually sterile ; 
in our practice we have found exactly the opposite condition. In a 
large number of families where both of the parents were affected with 
syphilis, they have had a large and numerous progeny. If the question 
is to be considered with reference to the class of prostitutes, they are 
usually sterile. The reason, however, is not easily attributed to syph- 
ilis, because they are usually affected with chronic gonorrhea of the 
cervix and also of the endometrium. The cause of sterility in those 
women is to be found rather in a chronic gonorrheal process than in 
syphilis. 

In private practice we have been able to follow families where 
both parents were affected with syphilis, but no gonorrhea existed : 



252 THE MEDICAL ASPECTS 

we have found the women rather prolific, and in a general way we 
can state that syphilis is seldom the cause of sterility in woman. 
Recent syphilis in woman as a cause of miscarriage is a fact, but the 
statement that syphilitic women are sterile does not agree with ordinary 
experience. Syphilitic women are usually inclined to erotic excitement, 
and syphilis seems to increase in them the tendency to lasciviousness. 

Syphilitic affections of the uterus, tubes and ovaries are not fre- 
quently found in practice. Jullien related one case of gumma of the 
size of a walnut on the cervix. In a great number of syphilitic women 
we have never met with such an occurrence. Primary chancres of the 
os uteri we have found several times. In the same way we have, in a 
few cases, seen mucous patches of the same organ. The hard chancre 
and mucous patches, however, are only temporary affections. They 
disappear after due treatment and do not leave any such permanent 
impairment of the organs as to prevent conception. 

Syphilis does not spare any organ or tissue of the body, and 
therefore the body of the womb, the tubes and the ovaries may be 
affected from this disease. Observations are rare and rather imper- 
fect. Gynecologists do not pay much attention to these cases, and so 
far no definite syphilitic condition of the womb, tubes and ovaries has 
been so described as to remove any doubt about their existence. 

It is possible that the ovaries are affected in secondary syphilis 
with a specific inflammatory process, with a tendency to resolution, 
as we observe cases of syphilitic epididymitis in man. Indeed, we 
often find women affected with secondary syphilis complaining about 
disturbances in the menstruation. This, although it may be the result 
of the general systemic affection on the blood through the syphilitic in- 
fection, may nevertheless be the result of a local secondary affection 
of the tubes and ovaries. 

Tertiary syphilis affects these organs in the form of gummata at 
a late period, as stated by Richet, 33 who found a case of gumma of 
the ovary. Lancereaux, too, referred to a case of well-defined tumor 
in the ovary, which disappeared after an antisyphilitic treatment. 
Cases of gummatous salpingitis were recorded by Buchard and Le- 
pine ; both tubes were hard and enlarged, and several gummata of the 
size of a hazelnut obstructed the passages. Fuller 34 also refers to a 
case of possible salpingitis from late syphilis, which resolved under 
large doses of iodide of potassium. 

From all the above considerations we may conclude that syphilis 

33 Richet. " Traite pract. d'Anatom. Chirurg.," quoted by Fuller. " Syphilis 
of the Generative Organs. A System of genito-urinary diseases," etc. 1893. 

34 Fuller, E. " Syphilis of the Generative Organs. A System of Genito- 
urinary Diseases," 1893. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



253 



has not a great influence in producing sterility in the woman. The 
syphilitic affections of the ovaries, tubes and of the womb, if secondary 
in character, are only temporary, easily resolving and not leaving any 
such permanent impairment of these organs as to prevent conception. 

Tertiary affections, deep infiltrating inflammatory processes, 
gummata, which have a tendency to destroy the affected organs, are 
capable of producing permanent alterations of the organs, and con- 
sequently of rendering the woman sterile. But syphilitic gummata 
of these organs have very seldom been recorded, so we can conclude 
that syphilis has very little influence in the sterility of woman. 

Jullien 35 followed up forty-three marriages of syphilitic persons 
and from them recorded 206 pregnancies, nearly five for each mar- 
riage, showing that syphilis does not usually favor sterility in the 
woman. The 206 pregnancies ended with the following results : 

Abortions 36 

Children dead at birth 8 

Children dead in the first year 69 

Living 93 

Of the 93 living children, 50 showed symptoms of syphilis and 43 
remained perfectly healthy. 

In the books of our private practice from 1883 to 1894, we can 
trace 24 families of which both parents had been treated for syphilitic 
manifestations at various periods. In three cases healthy parents 
with healthy children became infected later in their married life, and 
the results were abortions. 

In these 24 families where both parents had been infected, 96 
pregnancies occurred, four each, with the result as follows : 

Abortions, 35. 

Born living, 61. 
Of the 61, eight died in the first three months with syphilitic cachexia ; 
of the remaining 52, 9 showed symptoms of hereditary syphilis, 
mucous patches, ulcerations, papular eruptions, sucutaneous gummata, 
dactylitis, but all have recovered and are living. Six died of inter- 
current diseases, diphtheria, pneumonia, cholera infantum. Thirty- 
eight are well and have shown so far no symptoms of syphilis. 

From all these considerations we can deduce that syphilis does 

not prevent conception, although it kills the offspring or affects it in 

various manners. Children affected with hereditary syphilis are more 

liable to, and more easily affected by other morbid causes, and often 

they die from intercurrent diseases. 

35 Jullien, L. "Documents sur la Syphilis Hereditaire." Jim. de Derm, et 
Syph., 1891. 



254 THE MEDICAL ASPECTS 

SYPHILITIC IMMUNITY 

As long as a person is under the influence of the syphilitic virus 
he is not liable to be reinfected. The assertion that syphilis is not 
repeated on the same individual, or in other words, that whoever has 
contracted syphilis once, cannot be reinoculated (Ricord's law), has 
long ago been found untrue. 

Syphilitic immunity in infected persons is due to the saturated 
condition of the fluids and solids of their organism with syphilitic 
virus, and to the capacity of the organism to produce antitoxins to 
counteract the poisonous influence of the virus. The virus, however, 
in time and with treatment gradually loses its poisonous influence. 
This fact is ordinarily seen in every syphilitic family, when the first 
pregnancy ends in miscarriage, the second in premature birth, the 
third babe is born with some syphilitic manifestations, and the others 
well, showing only faint signs of the disease. 

From year to year the virulence of syphilis is bound to diminish, 
and gradually babes will be born with no signs of syphilis, or with 
so mild an infection that it will probably only reveal itself some time 
late in life. 

This diminution of the intensity of the virus occurs slowly and at 
times in a saltatory way. In some syphilitic families a healthy babe 
is born, and the next will show signs of hereditary syphilis. 

It seems that the syphilitic germs in the organism of the father, 
after a certain time and after some treatment, are unequally distributed 
in the organs and tissues. Moreover, there has to be taken into con- 
sideration the activity of certain cells of the organism, which on being 
conglomerated may offer so great a power of resistance as to render 
the germ powerless to spread its virulent influence. The result of an 
infected babe or of a healthy one may depend on mere accident in 
the presence of the germ in the spermatozoon. 

In this case it happens that the syphilitic germ from the father 
invades the developing organism of the fetus, and the mother remains 
intact. It seems that the mother must acquire a certain immunity 
against the affection afflicting the offspring, which protects her against 
infection. 

Colles' Law. — This material immunity has given origin to Colles' 
law, which was after a while confirmed by Ricord, Diday, Fournier 
and others. It can be thus expressed that mothers who bear syphilitic 
children from fathers affected with latent syphilis escape the disease 
entirely or pass through a modified form of it. Their children, af- 
fected with mucous patches of the tongue, of the lips, suckling the 
breast of their mothers do not infect her, but if thev were to suckle 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 255 

the breast of any other healthy woman, she would be positively 
infected. 

It can be better understood to-day with the light of the recent 
bacteriological studies, and the difference between microbic virus, 
which infects directly, and its toxins, which, according to Jacobi, 36 
may cause immunity to the mother. The spirochaetae of syphilis from 
the father invade the organism of the fetus, and the mother, by means 
of the toxins, acquires immunity against the affection afflicting the off- 
spring. 

Fellner explained this fact by analogy with cases of intra-uterine 
infection from variola. He collected a number of cases, where the 
mother remained healthy, or had only a mild eruption of variola, 
while the babe was born covered with pustules, or soon after birth 
showed a severe case of variola. 

Kassowitz 37 objected to the views of Fellner, for he claims that 
the immunity of the mother in the case of variola is only apparent, 
and has nothing to do with the immunity of the Colles law. Kasso- 
witz believes that the mother in spite of the infection of the fetus is 
immune, as many women in these circumstances, examined carefully 
at different times, have never shown signs of syphilis. A syphilitic 
fetus from a man affected with an old syphilis is not so virulently 
infected as in the case of a recent syphilis. 

In some cases of the kind the treatment of the father alone has 
been sufficient to obtain after a while healthy children, which could 
not have happened if the mother too had been infected. It has also 
occurred that a woman who has given birth to syphilitic children, after 
the death of her syphilitic 'husband has married a healthy man, and 
all the children have been perfectly healthy. In this way a woman 
may have healthy children from healthy men and syphilitic children 
from syphilitic men in alternation. 

The fact of possible infection of a child after a healthy one and 
the infection of mothers by conception always renders this kind of 
immunization rather doubtful and questionable. We have already 
seen that this law has been greatly diminished in its intrinsic value by 
the experiment of Caspary, above mentioned, which has positively 
shown that the immunity of these mothers is produced by the saturation 
of their system with syphilitic virus or with its toxins. We have 
already stated that the expression of absolute well-being, ought to be 
changed into apparent well-being, so as to reach the truth of their 
physical condition. 

36 Jacobi, A. "Hereditary Syphilis." Am. Textbook of Gen. Urin. Dis. 
Syphilis, etc. 1898, p. 730. 

37 Kassowitz, M. " Vererbung der Syphilis nnd placentare Uebertragimg 
der Variola." Wieii. Med. Wochensh., 1903. Ref. Monatshf. t. prakt Perm.. 
Bd. 38, No. i. 



256 THE MEDICAL ASPECTS 

Prof eta's law. — From what we have seen, just the reverse of what 
happens to the mother may happen to the child, which coming into 
the world from syphilitic parents has an innate tendency, which pro- 
tects him at least temporarily from syphilitic infection. Observations 
of this kind have originated another not less celebrated law, known as 
the Profeta's law. " Children born from mothers infected directly 
before or during pregnancy, as a rule are born healthy, and remain, 
at least for a certain period of life, protected against the disease." 

This law finds an explanation in the power of the placenta, which 
being already formed is able to oppose a strong barrier to the en- 
trance of the syphilitic germ protecting the child with its mechanical 
action. Moreover, the child would be saturated with the toxins arising 
from the biological activity of the spirochaetse in the system of the 
mother, which gradually brought to the fetus, without producing in- 
fection, would be responsible for his immunity. 

Children from syphilitic mothers have always shown, at least for 
a certain time, immunity against infection, so that the mother with 
syphilitic manifestations may kiss, nurse, and give them her breast 
without fear. Profeta 38 published the result of his observations, and 
it was readily accepted by Diday, Fournier, Mauriac, Baumler, Hutch- 
inson, Kassowitz and others. The sense of this law was then extended 
to the influence of the father, and also to the mother, who, suffering 
with tertiary syphilis, are able to transmit a certain immunity to their 
children against acquired syphilis. Finger 39 then formulated Pro- 
feta's law : that children from syphilitic parents may be born free from 
syphilitic manifestations, especially when the mother alone is infected, 
and the infection has occurred after conception. Immunity can be 
transmitted to the fetus directly through the ovum or the spermatozoa. 
When the father or the mother affected with an old syphilis at the 
time of conception had their tissues and their systems so saturated 
with toxins arising from syphilitic processes that they could not be 
affected any more, they have transmitted as heredity a true immunity. 
The toxins also in the case of an infected mother can be brought to 
the developing fetus through the placenta and produce an intra-uterine 
inherited immunity. 

In support of this law there have been produced by Finger some 
observations of young men born of syphilitic parents who could have 
intercourse with syphilitic women without being inoculated. The ob- 
servations of Baerensprung of mothers infected during pregnancy, 
who having given birth to a healthy child, did not infect him with 
their kisses. 

38 Profeta. " Sulla sifilide per allattamento." Lo sperimentale. Firenze, 
1865. 

39 Finger. " Ueber die vererbte Syphilis." Finger. Archiv. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 257 

Although the Profeta law has found in its support a long- series 
of observations from Profeta himself, and after a while it called the 
attention of Caspary, Finger, Ogilvie, Briiggeman and Gliick, yet it 
has received a strong blow from the observations of Tarnowski 40 on 
the syphilis binaria. 

Behrend in 185 1 had already referred to two cases of infection 
in children at the time of birth from their syphilitic mother. Mireur 
referred to a case of a child born free from syphilis, from syphilitic 
parents, who was infected by his father by a kiss on his lips when two 
years old. Cases of the kind have been referred to by a large number 
of observers and Finger himself has after a while called the attention 
to twenty cases of exceptions to Profeta's law. 

Tschlenow 41 together with Ogilvie 42 denies the existence of an 
inherited immunity from the father, and they believe that in the cases 
brought as a support of this hypothetical immunity, very likely little 
was known in reference to the anamnesis of the parents and of the 
concerned person. Upon the authority of Hutten, Mireur, Bar- 
thelemy, Eson, Erb, Goldflam, Paul, During, Pileur, Thibierge, Ogil- 
vie, Tschlenow, etc., cases of newly acquired syphilis have been ob- 
served in persons born from syphilitic parents, and among them some 
were after a while affected with parasyphilitic affections inherited by 
their father. 

The cases of Barthelemy, Blondel and Ogilvie, where the parties 
showed immunity for a certain time and then were infected with 
syphilis, would go to show only a temporary immunity. Syphilis of 
the father, so far as it concerns the immunizing of the offspring, seems 
to have no protective nor attenuating action on him. 

According to Ogilvie and Briiggeman the part of Profeta's law 
referring to inherited immunity from the father ought to be left out. 
It is not so, however, for that which concerns maternal syphilis, which 
if it is so constant and persistent in its transmission to offspring must 
nevertheless produce a more effective immunity. In fact, the papular 
'form of syphilis of the mother seems to have an efficient protective 
action, in preference to the gummatous eruptions, which would be 
entirely inefficient. 

40 Tarnowski, B. " Die atypischen Formen der Syphilis." Russ. Journ. f. 
Hant u. ven. Krank., 1901, No. 1. 

"Die syphilitische Familie und ihre absteigende Generation," 1901, H. II, 
12; 1902, 1, 2, 3. 

"Die verdoppelte Syphilis und syphilitische Vererbung." Prakt. Wratsch., 
1902, i, 2. 

41 Tschlenow, M. " Zur vererbten Immunitat gegen Syphilis und iiber das 
sogenannte Gesetz von Profeta." Monatshefte f. prakt. Derm., Bd. 36, No. 9. 

42 Ogilvie. " Congenital Immunity to Syphilis and the so-called law of 
Profeta." Brit. Journ. of Derm., 1899. 



258 THE MEDICAL ASPECTS 

Any theory we wish to accept in reference to tertiary syphilis, 
whether the attenuated virulence of the spirochaeta, as Neisser and 
Jadassohn claim, or the diminished quantity of the same, according 
to Klotz, or the toxine theory as given by Finger and During, it is 
commonly admitted that an infected mother, when she has reached 
the tertiary period, has already passed the most contagious and in- 
fectious stage in the evolution of the disease. Consequently a child 
born at this time cannot inherit a true and effective immunity against 
syphilis. Exceptions, however, have been found and have been re- 
ported, and have been explained by Ogilvie by a peculiar irregularity 
of the contagiousness of syphilis. 

We have already seen that the inoculation of syphilis in its ter- 
tiary form is still doubtful. From our experience we have also seen 
that women affected with ulcerated gummata have given birth to 
healthy children. All tends to show that syphilis at that period is not 
easily inoculable, and it is also not easily transmitted to the offspring. 
Together with Neisser we refuse the idea of Ehlers, which was to 
establish as a dogma the non-infectivity of tertiary syphilis. In the 
same way the assertion of the non-transmissibility of tertiary syphilis 
to the offspring we believe with Fournier to be a mistaken one, and 
it must be considered as preposterous. 

All observations have a tendency to show that when syphilis has 
reached the tertiary period its virulence has been greatly attenuated, 
and its protective action in the children would be consequently dimin- 
ished. Immunity transmitted from tertiary syphilis to the offspring 
cannot be denied, but it is not so apparent as that proceeding from 
the condylomatous period, and must be also of not so long duration. 
Tarnowski believes that this immunity is gradually lost at the time of 
puberty. 

In this regard Tschlenow refers to two cases of infection in 
children of syphilitic women. In one, a little girl born healthy, of a 
woman with tertiary syphilis, at the age of five used to play with a 
babe affected with hereditary syphilis. A syphilitic initial lesion ap- 
peared on her lower lip with consequent symptoms of acquired syphilis 
The other occurred in a babe three months old, born of a woman 
who had shown secondary syphilitic manifestations. 

Although we do not see much immunity in these cases, yet 
Tschlenow claims immunity, which has been of a short duration only. 
In these cases we would rather deny, with Ogilvie, the existence of 
any immunity than admit a theoretical one, when the child escaped 
infection by some unknown or unaccountable reason. This reason 
may be found either in the time which has elapsed from the infection 
of the mother, or from the effect of a well-directed treatment, 01 



Plate XIII 




Large Papular Eruption 




1 



Rupioid Form 

Child died of pneumonia 




DlATROPHY OF RlGHT HaXD AND 

Left Arm 
Child died of eclampsia 

Examples of Congenital Syphilis 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



259 



from the influence of both. It is quite sure that if both children were 
infected, one after five years and the other after three, months, they 
were not syphilitic and they were capable of receptivity of the virus. 

Immunity, however, from syphilis is not to be denied. Tar- 
nowski referred to one of the most striking examples. The daughter 
of a syphilitic father was married to a man who had a papular syphi- 
lide ; in spite of repeated intercourse, she did not become infected. 
This could not have happened unless through the protecting power 
afforded by syphilis, wmich prevents a syphilitic person from re- 
infection. 

In our City Hospital, in O ward, we had under our service a 
colored prostitute nineteen years old affected with an eruption of 
ulcerated mucous patches of the labia majora and minora, and also 
of the tongue and tonsils. These symptoms were accompanied by 
general adenopathy, and showed a syphilitic infection in the condy- 
lomatous stage, between the eighth and the tenth month. The girl 
was of poor physique, weak minded, extremely pale, her right eye 
had a staphyloma cornese, the result of a parenchymatous keratitis. 
She had characteristic Hutchinson's notchy teeth, and the tibiae, 
somewhat bent anteriorly, were rough and uneven. 

All tended to show that she had been born with congenital syph- 
ilis. It was not possible to obtain a family history, from her nor from 
others, but from the symptoms it clearly appeared that it was a case 
of syphilis binaria. In this case hereditary syphilis did not afford 
any protection, or at least only temporary protection. 

We do not doubt for a moment that in the system affected with 
syphilis there must be a certain antagonism between the virulent 
element and the chemical products. From this antagonism must 
arise, as Pellizzari 43 has maintained, a certain refractory condition 
of the system at the period of the general manifestations, which ren- 
ders it immune from reinoculation of the virus. This peculiar con- 
dition prompted Pellizzari and many others to try the treatment of 
syphilis by means of the serum taken from patients affected with 
syphilis, when they have reached this degree of immunization. 

An important question, which in the present condition of science 
cannot be resolved, is whether these toxic products are the result of 
the biochemical functions of the syphilitic germs, or whether the 
toxins are produced from the chemical alterations of the pathological 
tissues. Another far more interesting question is whether those 
chemical products formed in the morbid foci are those which cause 
immunity, or rather whether those pathological alterations are capable 

43 Pellizzari, C. " Tentativi di attenuazione della sifilide Atti dell' XI Con- 
gresso Medico Intern.," Vol. V. 



2 6o THE MEDICAL ASPECTS 

of causing the organism to produce albuminous products, antitoxins, 
which would be capable of counteracting the others arising from the 
germ. Both these conditions of the system would explain the im- 
munity of the mother from her syphilitic child and of the child from 
the syphilitic mother. 

The capacity of the organism to produce antitoxins is believed 
by Pellizzari to be the cause of the benignity or of the malignancy of 
syphilis. The insufficient production of these antitoxins would leave 
the virulent element free to deteriorate the system, revealing itself 
in the most destructive forms of the disease. 

Returning to the question of immunity and more especially to 
the law of Profeta, we must confess that a great deal of theorizing 
has been done on this subject. We agree with Ogilvie and Tschlenow, 
that it is extremely rare, scarcely possible, that a syphilitic woman 
brings to light a babe entirely free from syphilis, and that after her 
delivery she show symptoms of a condylomatous nature, which are 
capable of infecting. Vice versa, it is fully as rare and scarcely 
probable that infection may occur in a babe through suckling one 
year after, when he could already have been infected by his mother. 

Ogilvie 44 does not believe much in cases of post-conceptional 
syphilis, and he finds, moreover, that an early infection of the babe 
may be easily mistaken for hereditary syphilis. Profeta 45 in replying 
to his remarks, published the observation of a case where the im- 
munity of the child was very apparent. A healthy babe born of a 
syphilitic mother could not be suckled by her on account of mastitis 
of both sides of the breast. Her sister, out of kindness, offered to 
give her breast to the babe. She was suffering with a recent case of 
syphilis and underneath both nipples she had mucous patches. The 
babe suckling those nipples, together with the serum from the moist 
papules, did not contract syphilis, thus showing immunity. 

Another not less striking example of immunity brought up by 
Profeta was that of a woman who became infected at the end of the 
seventh month of gestation. Secondary manifestations began to ap- 
pear just at the time of the delivery, in rather a severe form. She 
gave birth to twins, of which the first was healthy, the second syphi- 
litic. The mother had all the most varied eruptions of syphilis, but 
her breast was spared. The second babe was covered with eruptions 
from head to foot, with moist eruptions of the mouth. Both babies 
were together, and were fed at the same bottle. Any other babe would 

44 Ogilvie. " Congenital immunity to syphilis and the so-called ' Law of 
Profeta.'" The Brit. Jonrn. of Derm., 1899. 

45 Profeta,. G. " Variazioni su motivi di sifilide congenita e per allattamento." 
Giorn. Italian di mat. e della pelle., 1900, p. 165. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 261 

have been positively infected, and yet the uninfected one remained 
healthy, and at the age of nine had never shown signs of syphilis. 
Opportunities for infection were always at hand, and immunity only 
could save the child from being inoculated. 

In spite of such striking illustrations of syphilitic immunity, 
Gluck 46 denied entirely the immunity and the existence of Profeta's 
law. He maintained that either in cases of post-conceptional infec- 
tion, the babe is killed in utero, abortion, or comes into the world with 
congenital syphilis. Children born absolutely free from syphilis of a 
syphilitic woman at a period when she is still capable of infecting, 
are such a rarity that a law based on them cannot find any support. 
In those rare cases where a child is born of a syphilitic woman and 
is free from syphilis, Gluck advises that resort be had to artificial 
feeding, rather than to let the woman give her breast to the babe. 
He has no confidence in this so much talked of immunity. 

From our own observations in the venereal ward we must state 
that in several cases of post-conceptional syphilis we have seen babies 
born perfectly healthy from mothers affected with syphilis in macular 
and papular forms. In one case the mother had so thick an eruption 
of mucous patches of the labia majora that for our protection rubber 
gloves had to be used to deliver her, and to our surprise the babe 
was healthy, well nourished, and as long as it remained under our 
observation it did not show signs of syphilis. 

We agree with Tschlenow that the Prof eta law has been subject 
to much distention, or rather distortion, for which Profeta is not re- 
sponsible. We cannot deny this law, especially that which concerns 
post-conceptional infection ; we have had several cases where infection 
of the mother had occurred between the third and the sixth months 
of pregnancy. The babe which was born from a mother affected with 
mucous patches of the vulva, above referred to, was separated from 
her and was nursed artificially in the children's ward. It remained 
there for thirty-six days and did not have syphilitic manifestations in 
that time. 

From the observations of Profeta and others, we believe in an 
immunity given by the mother to the child and resulting from the 
presence of antitoxins in the system, an immunity which is found 
also in other infectious diseases. In syphilis it is so well marked that 
we find that a person while infected with syphilis cannot be reinfected. 
It is not beyond the range of possibility that the fetus already de- 
veloped in utero in the case of post-conceptional infection is saved by 
the compact structure of the placenta from the invasion of the syphi- 

46 Gluck. " Ueber das sogenannte Profetasche Gesetz." Med. Wochenschr., 
1902, No. 9. 



262 THE MEDICAL ASPECTS 

litic germs, and is born free from syphilis, while, on the other hand, 
the toxins brought into circulation from the mother to the fetus have 
rendered it immune, an immunity which in ordinary cases is not of 
long duration. Cases of this kind are not very often met with, but 
their existence is undeniable. 

As to the immunity from a syphilitic father to his offspring, it 
is very questionable. Theoretically, however, we can admit that if 
syphilis is transmitted as a heredity a certain immunity can also be 
transmitted. The cases above mentioned, referred to by Finger and 
Tarnowski, are clear illustrations of transmissions of immunity against 
syphilis by heredity, but these cases are only exceptions and cannot 
form a law. 

Another important question is whether syphilis transmitted in a 
tertian* stage to the offspring is capable of protecting it from acquir- 
ing a new syphilitic infection. From the cases and from the exceptions 
of the Profeta law, we have seen that the inherited immunity is onlv 
of short duration, and children who had escaped contagium in the 
first months and years of life have been infected later on. In the case 
above referred to, although lacking a family history, it is clearly 
shown that the inherited luetic symptoms of a tertiary nature, if 
of any value for a certain time in immunizing the girl, did not keep 
her from being infected with a fresh case of rather severe syphilis. 
Another case was that of a young man twenty years old who showed 
dystrophy of the hands, with unmistakable signs of a periosteal 
syphilitic process of the tibiae and of the skull, and who came to the 
hospital with an initial chancre and macular syphilide. In this case 
it was clearly shown that if hereditary syphilis in the form of tertiary 
symptoms can produce immunity for a certain time, this immunity is 
lost after a while and a new infection can betaken, sypliilis binaria. 

A case of this kind has been reported by Petrini de Galatz 4T in 
a young man twenty-two years of age, who showed signs of past 
syphilitic affections of the bony system, together with a dystrophic 
condition of his teeth. Although the history of the syphilis was not 
clear, yet the condition of the frontal bone, and his teeth, was at- 
tributable to hereditary syphilis. He was under treatment for a 
maculo-papular eruption, which followed an initial lesion of recent 
inoculation. Petrini de Galatz considers with some reserve this case 
as one of possible reinfection, and of the kind considered by Tarnowski 
as syphilis binaria. 

Immunity at times is very perceptible ; children remain well while 

47 Petrini de Galatz. " Un cas de stigmates heredo-syphilitiques et de 
syphilis acquise chez le meme individne." Bcitrage sur Derm, una 1 Syphilis. 
Festschrift fur Prof. Neumann, 1900. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 263 

exposed to a continuous source of contagium, and it seems that im- 
munity is increased, as was shown by the experiments of Ehrlich. 

The reason of immunity being increased or weakened is found in 
the systemic individual conditions, in the quantity of the poison, in 
the capacity of the body to generate anti-toxins, and in the peculiar 
predisposition of the system. It may remain for a certain time, and 
then ceasing its protective influence, the child may undergo syphilitic 
infection. In most cases these adolescents are liable to show no more 
syphilitic manifestations, but rather parasyphilitic forms. Often in 
childhood they are subject to eclampsia, later on to epileptic fits, 
which are relieved and sometimes cured by the iodides. Some will show 
an arrest of development tending to dwarfism, or others will remain in 
a condition of infantilism. 

From the effects of syphilis, nearly all of them have their system 
so liable to other diseases that they are quite frequently affected with 
tuberculosis, or die with other intercurrent diseases. Some other 
cases towards puberty will show late syphilitic lesions, which, as we 
have seen, belong to cases of retarded syphilis. 

The fact stands, that in all cases of syphilitic infection before 
conception or during pregnancy, if the babe escapes syphilis before 
it is born, any inoculation of syphilis is not possible between mother 
and babe. The babe exposed during embryonal life to infection on 
account of the nutritive exchanges between fetus and mother through 
the utero-placentary circulation would, had its condition been favorable, 
have been infected before its birth, after which it can be infected with 
syphilis only later on, when with the growth of the body his organism 
has been renovated, thereby losing its immunity. The immunizing 
power must be found in the toxins, and in the capacity of the system 
to produce antitoxins. If we are to accept the views of Finger the 
toxins would be excluded from reaching the system of the fetus by 
the placenta. The exceptions to the law would be the result of the 
condition of the placenta or of the system unable to produce anti- 
toxins. Hochsinger 48 for the exceptions to Colles' law gave us an 
explanation the inability of the organism of the developing fetus to 
produce toxins, which if formed would render the mother immune. 

In conclusion we can say that syphilis, like any other infectious 
disease, is susceptible to a certain degree of immunity, which is re- 
vealed in acquired as well as in hereditary syphilis, an immunity, 
however, which is usually not of long duration. 

48 Quoted by Tschlenow, 1. c. 



264 THE MEDICAL ASPECTS 



SYMPTOMS AND CONSEQUENCES OF CONGENITAL AND HEREDITARY 

SYPHILIS 

"When the father, or both parents, being tainted with syphilis, 
have a successful cohabitation, the syphilitic germ is carried to the 
ovum, where it develops in the first- formed cells, and every organ 
of the developing embryo is saturated with the disease. The virulence 
is too great, the frail organism cannot stand so deep an infection, and 
consequently after a few months it dies. 

When the fetus dies after the third or fourth month of utero- 
gestation, very few or no characteristic pathological alterations can 
be found in a macroscopical examination. When the fetus dies later, 
alterations are then quite remarkable. W T e have already had occasion 
to speak of pathological alterations in the maternal placenta in the 
form of gummatous foci in late syphilis of the mother, but in these 
cases we will find the fetal placenta more often affected in its villi, in 
the form of nodules, which compress the circulation. We have already 
found that the blood vessels entering the structure of a syphilitic 
placenta show the same peculiar alterations in their tunics which are 
so characteristic of the syphilitic angioitis. This causes an obstruction 
of the blood vessels and as a consequence of the imperfect develop- 
ment this organ appears small, flaccid, and easily breaks, and weighs 
much less than a normal placenta. In some places of the placentary 
stroma hemorrhagic infarctions are found where tissues have been 
destroyed, facilitating a direct communication of the germs. The 
amniotic fluid is turbid, sticky, dark and foul, the epidermis of the 
little body is macerated and is detached in large shreds. In many 
autopsies of fetuses dead between the fifth and the sixth months the 
gross anatomo-pathological alterations were very scarce, and with 
the exception of a somewhat enlarged spleen, nothing else interesting 
could be found. 

In some cases the liver also is found somewhat enlarged, the 
tissue is dark, congested, and interspersed with some yellowish points. 
These spots, somewhat resembling miliary tubercles, are nothing else 
than small cell infiltrations, with proliferation and induration of the 
interstitial tissues, gummatous in character. Hochsinger in 148 cases 
of hereditary syphilis found enlargement of the liver 46 times and 
in five autopsies enlargement of the spleen and of the liver, without 
icterus or ascites. Chiari. although he did not find marked enlarge- 
ment of the liver, noted a hyperplastic infiltration around the biliary 
ducts sufficient to explain the presence of the jaundice. Abraham 
Jacobi demonstrated a case of cirrhotic atrophy of the liver of syphilitic 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 265 

origin. All these observations referred to show that syphilitic infec- 
tion produces early and intense ravages in this organ, and in many 
cases it is the cause of death. 

Macroscopic alterations of a gummatous nature are liable to be 
found in the pancreas, in the kidneys, in the testes and in the digestive 
tract in the form of infiltrations or ulcerations. 

In two cases of post-mortem in syphilitic babies born dead nearly 
at full term, we have found the lungs very dark, thick and deeply 
congested, interspersed with whitish nodules, showing an interstitial 
inflammatory process, to which death was attributed. The bronchial 
glands have been found enlarged in several cases. Demme found 
gummata in the thyroid gland in a case of retarded syphilis. 

It is not a rare thing to find the thymus gland affected with heredi- 
tary syphilis, and the works of Jacobi 49 have contributed a great deal 
to the elucidation of its anatomo-pathological alterations. As a vas- 
cular organ the blood vessels are deeply affected, and as a consequence 
a thickening of the whole organ has taken place. In some places, 
masses of hypertrophic connective tissues were found around the 
blood vessels, causing pressure, just as in the interstitial inflammations 
of the other organs. This hyperplasia seems to be characteristic of 
hereditary syphilis, and is accompanied at times with enlargement of 
the glands. Abscesses have been found in the thymus of syphilitic 
babies by Dubois and Haugsted, and hemorrhages by Fuerth and 
Weber. 

The heart, although very rarely affected, has been found in a few 
instances to show signs of fibrous myocarditis and gummata. In a 
fetus stillborn at the eighth month, Kantzow and Virchow found a 
myoma at the base of the heart and miliary gummata in the right ven- 
tricle. Syphilitic myocarditis was found by Hutchinson, and fibrous 
myocarditis and endocarditis by Wendt. 

The pericardium has been found with miliary syphilomata and 
obliterating adhesions. 

The pathological anatomy of the nervous system in the fetus has 
so far revealed very little. One case of cerebral syphilis in a babe ten 
months old was reported by Rosa Engelman. Two more cases have 
been referred by Rumpf, but it is the common opinion that cerebral 
gummata in babies are very rare, and Starr claims that their presence 
below the twelfth year is only rarely found. 

In reference to the spinal cord we will refer to the conclusions 
of G. Gasne, quoted by Jacobi, that the meningo-medullary changes in 
the fetus, infant and adult are identical, that the ganglia are infiltrated, 
but the nerve cells are mostly intact. He found fibrous thickening, or 

49 Jacobi. Virginia Medical Monthly, May, 1895. 



266 THE MEDICAL ASPECTS 

infiltration with small cells, in the septa and in the blood vessels. The 
process has been found disseminated mostly in the posterior surface 
of the medulla and of the meninges. 

When the fetus has escaped death in liter o, it is born, in some 
cases, somewhat prematurely, is anemic, of an ashy appearance, so 
poorly developed and so feeble that it survives only a few hours. In 
several of these cases, which we have had under our observation, the 
autopsy did not reveal gross perceptible alterations, with the exception 
of a small enlargement of the spleen, and in a very few instances 
symptoms of epiphysitis were present. 

Sometimes infants are born at full term showing eruptions of 
papules or bullae. They are then under so severe a degree of infection 
that they do not live more than a few days. Their general appearance 
is usually very bad ; the little body is wasted, the skin is wrinkled, 
their cry is weak, the nose stopped up, they have no strength to 
take the breast, and they usually die between the first and second 
week. In the majority of cases the infant is born apparently healthy, 
and only after a certain time shows the characteristic symptoms of 
syphilis. 

The earliest eruption we have seen in syphilitic children was the 
bullous eruption of the soles and palms, the so-called syphilitic pemphi- 
gus, which in one of our cases began three days, and in another five, 
after birth. The more intense the nature of the infection is, the 
earlier the cutaneous symptoms occur. Usually eruptions make their 
appearance between the second and sixth weeks. An interesting sta- 
tistical table taken from iooo cases of syphilitic babes by Miller of 
Moscow, and quoted by Holt, 50 tends to show the time when symp- 
toms are most apt to occur. 

ist week, 85 
2nd " 138 
3rd " 240 
4th " 177 

alter the 8th week, 140 

In most of the cases the eruption is preceded by general svmptoms. 
The babe wastes away, his nose is affected with coryza snuffles, which 
prevents him from suckling, his cry is weak and hoarse, all showing 
that the mucous membranes are already involved in a catarrhal in- 
flammation. 

At this time a papular eruption affects the hands and face of 
the babe in the form of small papules, rather confluent, which after 
a while spread to the arms, body and legs. Mucous patches are seen 
on the lips, around the genitals and the anus in an excoriated or ulcer- 
ated form. The eruption is usually accompanied by a mild fever, 
50 Holt L. E. " The Diseases of Infancy and Childhood," 1897, p. 1059. 



5th week. 


86 


6th " 


54 


7th " 


50 


8th " 


30 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 267 

99 to 101 . and in some cases with a tenderness of several joints due 
to acute epiphysitis. The joints may be slightly swollen, and the 
babe cries every time that he is handled on account of their tender- 
ness. 

In other cases of severe infection the babe's general nutrition 
suffers. He decreases in weight, becomes very anemic, whines and 
frets, especially at night. His face, wrinkled and drawn, takes on that 
characteristic aspect of an old person. His skin, destitute of panni- 
culus adiposus, is so wrinkled that it can be raised in large folds, and 
has taken on so peculiar a sallow color as to resemble cafe ait lait. 

In some cases the skin becomes dry, rhagades of lips, nose, ears, 
eyelids, mouth and anus are formed. Roseola appears in the form 
of large copper-colored spots, which soon, on account of increased 
exudation and infiltration, become elevated, forming papulae in the 
center. Gradually on account of the reabsorption of the effused ele- 
ments the papula fades out, and the epidermis covering them dries up, 
forming scales. In other cases, on account of increased exudation 
the epidermis is raised up in the form of vesicles, their serum on ac- 
count of the presence of the pus cocci in the skin is soon changed into 
a purulent secretion. This forms thick crusts which cover the surface 
of the excoriated lesions, which may convey the idea of a diffused 
impetigo. In other cases, however, the purulent secretion coming 
from distinct lesions when a superficial ulceration takes place in their 
center, they form a hard, dry crust, which is characterized as rupia. 
These peculiar eruptions are in some cases found together and un- 
doubtedly show the severity of the infection. 

Quite frequently around the anus and the genitals the skin is 
covered with moist papules, mucous patches, which are brown red in 
color, covered with a thin epidermis and raised above the level of the 
normal skin. The epidermis in these regions, macerated by the pres- 
ence of urine, feces and perspiration, is easily abraded ; the patches 
are excoriated and soon superficially ulcerated. The surrounding 
skin becomes inflamed in the form of a diffused intertrigo. Some 
mucous patches are found in the mucous membranes of the genitalia 
of the anus and of the lips and tongue. 

The fingers, especially the last phalanges, are bluish red, and 
sometimes show papular infiltration of the finger nails, syphilitic 
paronychia. 

Quite often we have found that children show syphilitic dactylitis. 
the bones of the phalanges swell, the medullary canal is changed into 
a large cavity, which increases and changes the size of the phalanx 
of the finger into a round or oval-shaped joint. The skin covering it 
is thin, bluish red, and distended. Sometimes the process is limited 



268 THE MEDICAL ASPECTS 

to the bone, at other times the fibrous tissues of the joints are also 
involved. 

The mucous membranes are affected with catarrh, so that from 
the nose flows a purulent secretion which occludes the nostrils and 
prevents the babe from suckling. The conjunctivae are also inflamed, 
and the cornea is liable to be affected with parenchymatous keratitis. 
The iris and the corpus vitreum may undergo interesting changes. 

The rectum is sometimes prolapsed and painful on account of 
rhagades and mucous patches. The lymphatic glands are usually hard 
and sclerotic. It is not the enlargement which accompanies the de- 
velopment of acquired syphilis, but rather recalls the shrunken and 
sclerotic condition of the lymphatic glands several years after syphilis 
has entirely disappeared. Under the exploring hand they are felt 
like shot, hard and movable. Anemia is quite marked and the spleen 
is somewhat enlarged. If the babe is left without treatment or if this 
is used too late, the babe runs down to a marasmatic condition, col- 
liquative diarrhea begins, and the babe dies of inanition. 

In some cases babies are born without apparent symptoms of 
syphilis though suffering with a severe infection in the viscera. This 
condition may continue through infancy and accompany them in child- 
hood. Keim, 51 of Paris, called attention to the necessity of treating 
luetic newborn children, although they may not show visible syphilitic 
manifestations. He referred to a family, the father of which had 
been treated for nearly three years for a mild case of syphilis. The 
mother never had shown any decided symptom of the disease, but 
she was not well, and consequently during her first pregnancy was 
subjected to antisyphilitic treatment. The first child was born healthy 
and never showed any sign of lues. During the second pregnancy no 
treatment was given to the mother; she gave birth to two babies, of 
which one showed immediately after birth, but the other not until 
six months later, evident symptoms of infection. The babies began 
to lose weight, they became pale and anemic, with disturbances of the 
digestive organs, and especially of the liver. 

The liver is often affected. In some cases it is enlarged and 
hardened, and ascites is present. Jaundice appears, though not often, 
a few weeks after birth, a circumstance which differentiates it from 
the common jaundice of the newly-born. 

YVe have already called the attention of the reader to the epiphy- 
sitis which is often found in cases of congenital syphilis with syphilitic 
eruption. In some of the cases of congenital syphilis without apparent 
manifestations the babe may be affected with osteochondritis, which 
in the beginning may pass entirely unobserved, when there is an 

51 Keim. La Syphilis. July, 1904. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 269 

absence of marked swelling. Gradually the bones are found some- 
what swollen and painful while the skin covering the swollen joint 
may appear red. The epiphysis may be separated by the diaphysis, 
and then marked crepitation is felt with some pain, not corresponding, 
however, to the entity and to the severity of the lesion. The humerus 
is affected in preference, and remains useless in pronation. This con- 
dition was named and described by Parrot as pseudoparalysis. 

It is not easy to determine how long syphilitic intestinal troubles 
will last, but in severe cases it is one of the determining causes of 
death in the form of colliquative diarrhea. 

An atrophy of the base of the tongue has been described by 
Lewin and Heller, 52 which has also been found in hereditary syphilis. 
The affection was described by Virchow under the name of atrophia 
Icevis basis Ungues. It consisted in a smooth depression of the pharyn- 
geal portion of the tongue, with an atrophic or hypertrophic condition 
of the lingual tonsils. Virchow established this alteration as a con- 
stant pathognomonic symptoms of lues. It is, however, not a charac- 
teristic sign of hereditary syphilis, but, as O. Seifert, Lewin, Heller 
and others have demonstrated, is mostly found in hereditary syphilis. 

Robinson, Fournier, Hyde and others have described as present 
in the mouth of the babies affected with hereditary syphilis, small, 
superficial, radiated, cicatricial patches in the form of leucoplasias, 
such as are found in adults with acquired syphilis. In our experience, 
however, we find in syphilitic adults a whitish thickened line of turbid 
epithelium, which runs from the angles of the mouth straight towards 
the molars, with small ramifications, but only rarely have we found 
it in the mouth of syphilitic babies. 

Congenital syphilis is the cause of interstitial hemorrhages in the 
form of petechias They affect the skin as purpura neonatorum and, 
as Mracek 53 has found, are the result of syphilitic alterations in the 
small and medium sized veins. Some hemorrhagic spots affect not 
only the skin, but have been found in the muscles, serous membranes, 
mucous membranes, the pleura, the pericardium, and even in the 
lungs and the glands. Jacobi has found hemorrhages of this kind in 
cases of severe congenital syphilis immediately after birth, or only a 
few weeks after. In rare cases hemorrhagic spots have been found 
under the periosteum with preference for the humerus. 

Syphilitic alterations of the blood vessels are repeated in the um- 
bilical cord. Franceschini 54 found the same specific inflammatory 

52 Lewin and Heller. Virchow' s Archives, Vol. 138. 

53 Mracek, F. "Syphilis hemorrhagica neonatorum," Arch, f. Derm, und 
Syphilis. 1887, XIX, p. 274. 

54 Franceschini, J. " La Syphilis," July, 1904. Ref. Monatshcftc f. prakt. 
Derm., Bd. 39, No. 6. 



270 THE MEDICAL ASPECTS 

process in the arteries as well as in the veins of the cord, accompanied 
by thick edematous infiltration of their tunics with thick and hardened 
places. Endoarteritis and endophlebitis are the causes of the altera- 
tions of the intima of these vessels, which may lead to their obliteration. 
From this condition of the blood vessels the Wharton layer suffers 
interesting changes; it is scanty, poorly developed, and shows a thick 
infiltration of leucocytes. When the cord is found in this condition 
it is a good sign for suspecting congenital syphilis, although the babe 
is born apparently healthy. 

When the babe is subjected to an appropriate treatment, and is 
helped along by proper feeding, it can be helped, yet if the infection 
is too deep and severe, the prognosis is doubtful. In very anemic 
babies, weak and low of weight, death may occur suddenly without a 
perceptible cause. 

Indeed, when syphilitic children are under treatment it is of 
great importance to keep note of their weight. In some cases it is 
possible from the weight of a babe to conclude as to the possibility 
of latent syphilis. Boissard and Deve 55 have seen children who in 
spite of their apparent good health do not increase in weight, and 
although the milk and the food have been changed, a diminution in 
their weight has constantly taken place and they have had a fatal end. 
In cases of this kind signs of lues are not found and so it is difficult 
to explain the reason for the decrease in their weight. Proof of the 
syphilitic origin of their denutrition is obtained from the result of the 
antisyphilitic treatment which in a short time shows its effect, the 
babe beginning to increase in weight. 

It is therefore of great importance to note the weight of the babe. 
A decrease in its weight may be a hint of the existence of latent 
congenital lues which otherwise would remain ignored, and by insti- 
tuting a specific treatment we can save the life of the child. 

Not rarely children with congenital lues suffer with eclampsia, 
and some are found affected with chronic hvdrocephalus. They are 
liable to all other morbid causes, so that they are quite often affected 
w T ith bronchitis and pneumonia, which may end their lives. Their 
skin is so easily affected by pus cocci through the abrasions or ex- 
coriations that quite often we find them suffering with furunculosis 
and deep abscesses of a specific origin. 

We have already seen that syphilis and tuberculosis are quite 
often associated together, one making the other more deleterious and 
malignant. There are unfortunate cases where syphilis is inherited 
from the father and tuberculosis from the mother. Caseous infiltra- 

55 Boissard and Deve. " La Syphilis." July, 1904. Ref. Monatshefte f. 
prakt. Derm., Bd. 39, No. 6. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



271 



tions are the result of both diseases, and it is very difficult to ascertain 
the existence of the tuberculosis unless tubercle bacilli are present. 
In a general way we can state that in hereditary syphilis when caseous 
infiltrations are found in the lungs, it is very likely that both affections 
are acting together. 

Hereditary syphilis has a great influence on the production of 
diseases of the nervous system, and also has an injurious influence on 
the development of anomalies in the mental functions, so much so 
that we are compelled to treat this subject in a separate article. 

GENERAL TREATMENT OF CONGENITAL SYPHILIS 

Treatment, which so wonderfully helps and cures acquired syph- 
ilis, shows its power in the relief and cure of congenital syphilis. When 
we have under our care a syphilitic babe we must always keep in mind 
that it is a danger for the spreading of syphilis to others. Conse- 
quently a syphilitic babe must be nursed by its own mother, because 
if it is given to a wet nurse it will surely infect her. In the same way 
girls taking care of the infant must be cautioned not to kiss it on 
the mouth. We remember a case of syphilitic infection in a young 
lady caused by the syphilitic babe of her sister. In this case the 
initial lesion was on the right cheek of the young lady where the 
mouth of the babe had accidentally touched her. 

We had under our care an old lady with the initial lesion on the 
index finger of her right hand, and which was caused by the syphilitic 
babe of her daughter. 

It is, therefore, necessary to be careful with syphilitic babies on 
account of the danger of communication of svphilis. In case the 
mother should not be able to nurse her babe, then rather than run 
the risk of infecting another person the babe should be nursed with 
the bottle. In the children's ward of the City Hospital as well as in 
our private practice, when the babe has to be nourished by the bottle 
we use sterilized cow's milk, which we direct to be diluted with a 
barley decoction. This mixture is well borne by the stomach and 
affords good nutrition for the babe. 

The treatment of congenital syphilis, as for the acquired disease, 
is local and general or constitutional. Rhagades, ulcers and moist 
papules must be treated locally. 

The babe when covered with a syphilitic eruption is bathed in 
a solution of bichloride of mercury every day for ten or fifteen minutes. 
The solution is prepared by dissolving from two to four tablets of 
vii grains of sublimate in six gallons of warm water in the bath tub. 
This gives a solution of a strength of from 1 to 12,000. Although 



272 THE MEDICAL ASPECTS 

Welander 56 denies any absorption at all of the mercurial preparation 
when the skin is normal, yet in this bath we find a remarkably beneficial 
local action. After a few baths dry papular eruptions soon fade and 
disappear, moist papules and ulcerated lesions soon clear up and begin 
to heal. Indeed, in the bath we do not see the local action alone, but 
also a beneficial general action due to the absorption of the mercurial 
preparation. It is true that the epidermis is a boundary between the 
internal organs and the external surroundings. It is deficient in blood 
vessels, yet it only limits but does not prevent absorption. Especially 
when the water of the bath is at a warm temperature, some is absorbed 
by the epidermis. Indeed, when a hand is kept for a long time in 
water the epidermis becomes whiter, thicker and somewhat distended 
from the penetration of water into its structure. When sublimate is 
dissolved in the water some must be absorbed. In the excoriated and 
ulcerated surfaces the absorption is more active. Yet from the use 
of the sublimate bath in acquired as well as in hereditary syphilis, we 
have always obtained satisfactory results. 

Coryza in syphilitic children is a troublesome symptom which 
prevents the babe from taking nourishment. An abundant secretion 
of muco-pus, sometimes tinged with blood, keeps discharging from 
the nostrils, which getting dry, forms thick crusts obstructing the 
passage of the air. The babe is compelled to breathe through the 
mouth, which becomes dry and causes great discomfort. This affection 
needs local attention. The nurse will be directed to remove the puru- 
lent secretion with a wet rag or cotton and inject by means of an 
ordinary glass dropper a solution of mentholated biborate of sodium. 

Biborat. Sodii 3 ss 

Menthol gr. i 

Aq. Camphorat. \ - • 

Aq. Destillat. f aa 3 1SS 

The nurse must be cautioned to make the injection in the nostrils 
while holding the babe in an erect position, in order to prevent choking. 
Fissures and mucous patches around the nose, on the lips, tongue, 
genitals, etc., have to be touched with a three per cent, solution of 
silver nitrate and then washed with water to remove the surplus of 
nitrate of silver. 

Ulcerated surfaces and excoriated papules are usually dusted with 
calomel and then covered with dry absorbent cotton to prevent con- 
tact with other surfaces. In case the dry dressing is not advisable on 
account of forming crusts, we prefer the application of a salve with 
white precipitate of mercury. 

56 Welander, E. " Wie und wo, sollen wir hereditar syphilitische Kinder 
behandeln?" Bcrl. klin. Wochenschr. Sept. 12, 1904, No. yj. 






TRANSMISSION OF SYPHILIS TO THE OFFSPRING 273 

Hydrarg. precip. alb gr. iv-vi 

Bismuth subcarb. ) 

Zinc Oxyd. f aa 3 ss 

Acid. Carbolic gutt. vi 

Vaselin. flav 3 i 

When we have to do with superficial ulcerated cutaneous gum- 
mata with ulcerations surrounded by a gummatous infiltration, we pre- 
fer the use of the emplastrum hydrargyri, which we spread on a 
cloth which is applied on the surface. From this application we have 
not only a local action, but also a general one on account of the ab- 
sorption of the mercury. 

In cases of ulcerated gummata, when the mercurial plaster is 
not longer tolerated, the application of iodoform salve will be found 
to give good results. It is necessary, however, to watch the use of 
iodoform on account of the frequent dermatitis which follows its use. 

CONSTITUTIONAL TREATMENT OF CONGENITAL SYPHILIS 

All external applications in syphilis will not be of much benefit 
unless fostered by the general or constitutional treatment. As for 
acquired syphilis, mercury is the remedy which brings about our 
therapeutic triumphs in congenital and hereditary syphilis. Mercury, 
when judiciously employed, has given in our hands wonderful results 
in infants wmo were already affected with syphilitic cachexia. 

In the same way as in the treatment of acquired syphilis, we can 
administer mercury to the babe by ingestion, by inunctions or by 
subcutaneous injections. The three methods are not chosen by acci- 
dent, but they are selected according to the condition of the little 
patient and the indications arising from the severity of the symptoms. 

In a case of congenital syphilis with secondary symptoms, when 
the affection has not too deeply affected the general nutrition, we select 
the administration of mercurial preparation by ingestion. Calomel 
has given us good results ; it brings the system more readily under the 
action of mercury. We give calomel to babies in a dose of 1-10 of a 
grain two or three times a day. The formula we use is as follows : 

Hydrarg. chlor. mit. . gr. iv 

Bicarbon. Sod gr. x 

Sacchr. alb gr. x 

M. div. in ch. aeq. No. 20 
One powder twice a day. 

This is easily given in a teaspoonful of water or milk. In our 
cases the administration of these powders has regulated the bowels, 
and we have never seen any trouble, although continued for several 
weeks. 



274 THE MEDICAL ASPECTS 

Mercury by ingestion to babies can be given in the form of gray 
powder, one grain four times a day ; as a solution of sublimate, one- 
sixtieth of a grain, well diluted ; also four times a day. In our ex- 
perience we prefer and advise calomel in the given formula. 

In case the babe should be troubled with diarrhea, then, rather 
than insist on the administration of the calomel, we resort to the 
mercurial inunctions. The ordinary mercurial ointment is diluted with 
the same amount of vaseline, and twenty grains of this mixture is 
rubbed daily into the soles, palms, back, axillae, etc., for a few minutes. 
The place to be rubbed must be changed, and the nurse must be 
cautioned not to wash the place soon after having rubbed it, in order 
to prevent irritation of the skin, and the • possible occurrence of 
eczema or mercurial erythema. After the inunction is made the 
surface will be covered with a piece of English lint to maintain the 
mercurial ointment in contact with the skin. 

In grave cases of congenital syphilis we have resorted to the 
deep injections of a mercurial preparation. Intramuscular injections 
with bichloride of mercury in congenital syphilis we have seen used 
with good results in the clinic of Dr. Ciarrocchi, in Rome. We have 
used injections in the g-luteal regions with five drops of gray oil, 
twenty per cent., once a week in the same circumstances, and we can 
say with more than satisfactory results. We can agree with Mon- 
corvo, Ferreira and Lang 57 on the decided preference for gray oil 
for injections in the treatment of congenital syphilis. In six of our 
cases of an aggravated form of congenital syphilis with papular and 
ulcerative cutaneous eruptions, and with symptoms of syphilitic cach- 
exia, four to six injections of five drops of the gray oil have rendered 
great benefit. As a consequence of the injections in babies, we have 
seen no trouble in the mouth or on the part of the bowels. Only in 
one instance the place of the injection became inflamed and formed a 
small limited abscess, but the babe had, at the same time, boils and 
cutaneous abscesses in different parts of its body. Consequently it 
was very difficult to prevent staphylococcic infection. When the 
symptoms begin to show signs of improvement we cease the injections 
and return to the internal administration of the mercurial preparation. 
Iodide of potassium, the other great remedy for acquired syphilis, 
also shows its beneficial effects in hereditary and congenital syphilis. 
It is indicated, alone or with mercurial treatment, in all cases of 
syphilitic lesions which point towards tertiary lues. When the tender- 
ness of the joints shows that there is a process of epiphysitis, or the 
condition of the bones shows periostitis, iodide of potassium must be 
given in sufficient doses. Likewise in the case of syphilitic dactylitis, 

57 Lang, E. Twentieth Century Practice, Vol. xviii, p. 319. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 275 

of cutaneous gummata, iodide of potassium must be given in a dose 
of from ten to thirty grains daily. It is well supported by the children, 
and in cases of urgent symptoms the quantity can be raised to the 
usual dosage of sixty grains per day. 

Although specific treatment must be kept up for a long time, yet 
it has to be given with some intervals of rest. As soon as the 
syphilitic symptoms have improved, we cease the mercurial treatment 
for a while, to give place to tonic and ferruginous preparations, in 
order to correct the anemia and to increase the nutrition of the babe. 
In the case of congenital syphilis, the specific treatment must be 
carried on for one year and more. The remedies and their administra- 
tion have to be changed according to the indications, so that if. in the 
beginning, on account of the severity of the infection, we have used 
sublimate baths and deep injections with the gray oil, when the 
symptoms subside we may follow the treatment with calomel or with 
gray powders in small doses twice a day, in order to maintain a 
certain degree of mercurialization. The symptoms and the degree of 
the infection are the guide for selecting the treatment, and also for 
advising us when it must be stopped or resumed. It takes good, 
heroic and constant treatment to destroy in the babe the germs of 
syphilis, which have been developed in his little organism at the time 
of his conception. 

PROPHYLAXIS 

When a babe is born with symptoms of congenital syphilis, from 
parents apparently well, it is the duty of the physician to advise them 
both to undergo a specific treatment. The health of the woman, who 
has been innocently infected by her husband, has to be protected, 
and she must begin a good and heroic treatment for her future 
health and for the welfare of their coming children. In some cases 
we may find objections on the part of the woman, who, ignorant of 
the disease which she has acquired, may refuse treatment on the ground 
of her feeling well. In our practice we have never found any objec- 
tion to treatment when we have mentioned to the woman the necessity 
of it on account of her children. We have never spoken the name of 
the disease, or told to what origin it must be attributed, but we have 
only explained that without a good treatment she cannot have healthy 
children. This reason has been sufficient to persuade the woman 
to take her treatment without any remarks. By the treatment of the 
syphilitic mother we can prevent abortion and bring the pregnancy to 
its full term. The babe may still come forth tainted, yet he is capable 
of resisting the disease and of tolerating treatment, whereby he will 
obtain recoverv. 



276 THE MEDICAL ASPECTS 

One also secures, by the treatment of syphilitic parents, and more 
especially the mother during pregnancy, the birth of a healthy babe, or 
at least without any syphilitic manifestation. Fournier 58 and Langle- 
bert 59 referred to splendid results obtained by treatment of syphilitic 
women during pregnancy, that clearly show its value and its efficacy. 

On the other hand, the results of syphilis left to itself in the 
mother as ignored syphilis, are absolutely frightful. O. Jersild 60 at 
the meeting of the Danish Dermatological Society, referred to the case 
of a young married woman, apparently in good health, who at her 
first pregnancy had a miscarriage between the second and third 
months. The second pregnancy reached full term, but the babe died 
seven weeks afterward, covered with a bullous eruption. The third 
pregnancy ended in abortion between the fifth and sixth months. On 
her fourth pregnancy she gave birth to a child, still living, but suffer- 
ing at present with parenchymatous keratitis. 

The fifth pregnancy had a full term, but the babe died when eight 
weeks old. The sixth pregnancy reached its full term, and the babe 
was born without signs of congenital syphilis. Her husband, a sailor, 
at this time began to suffer with brain symptoms, and died with 
dementia paralytica in a hospital for the insane. 

In her history, she could only mention the presence of a little 
wound in her lips some fifteen years before, and which she thought 
to be the result of fever blisters. She never had perceptible adenitis, 
nor did she ever notice any eruptions. The joints of both hands are 
at present affected with chronic arthritis, extremely painful, swollen 
and immovable. Some of the metacarpal bones have been destroyed 
in their epiphysis. 

Her daughter, born of the fourth pregnancy, was, until the eighth 
year of life, comparatively well, when she was affected with an eye 
disease which was diagnosed keratitis parenchymatosa. No alteration 
or deformity could be found in the conformation of her skull ; her teeth, 
with the exception of being somewhat wide in their implantation, 
showed no abnormality. 

There was no doubt that the husband had had an initial chancre 
of which the scar remained indelible on his glans, as was confirmed 
at the post-mortem, and that the general paralysis had been the result 
of the disease. The wife had been infected on her lip from the kiss 
of her husband, the scar being still there after twenty years. Syphilis 
had run a subdolous course, there being no perceptible manifestations 
until the disease had begun to affect the bony system. Of six 

58 Fournier, A. " Syphilis et Mariage." Paris, 1890. 

59 Langlebert. " La Syphilis dans ses rapports avec le mariage," p. 237. 

60 Jersild, O. Ref. Derm. Zeitschr. Bd. vi., 1899, p. 763. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 277 

pregnancies, four resulted in abortion, or the babe was born at full 
term and died a few weeks after birth. The child of the fourth 
pregnancy, although apparently well at the age of eight, began to 
suffer with parenchymatous keratitis, which is an essentially late 
syphilitic manifestation. 

Jonathan Hutchinson reported that he had observed many cases 
of syphilitic affections of the bones in children affected with hereditary 
syphilis. He found especially a variety of bone affection which has 
a great similarity to osteitis deformans, as it is characterized by thick- 
ening and bending of the bones. In reference to syphilitic keratitis, 
it shows only late in life, so much so that at about thirty it is still 
liable to afflict the tainted organism. The same observations have been 
confirmed by v. Hippel, 61 who, in a larg-e clinic for the diseases of the 
eyes, has had occasion to observe a large number of children affected 
with hereditary syphilis, who were suffering with affections of the 
bones and of the joints. He places their average number at fifty-six 
per cent. In most of the cases the affection was double hydrarthrosis 
of the knee joints. The various affections of the bones have nearly 
constantly preceded the keratitis parenchymatosa and both remain 
symptoms of retarded syphilis. 

Many sufferings for the mother and the future child can be 
avoided by the application of a well-directed treatment- during 
pregnancy. The influence of the treatment of the syphilitic mother on 
the developing fetus has been in our experience very beneficial, and 
we consider it a true prophylactic means, capable of avoiding, or at 
least diminishing, the effects of congenital and hereditary syphilis. 

Riehl 62 expressed some doubts as to the efficacy of the specific 
treatment of the mother for the benefit of the offspring. He believes 
that the general treatment given to the mother does not reach the 
fetus, which remains without any influence from the remedies. Others 
have gone so far as to state that specific treatment of the mother in 
the early secondary period is not only of no benefit to the fetus, but 
if too much continued, will have an unfavorable influence on the 
course of the pregnancy. Huguier 63 and Fonberg 6i have maintained 
that the constitutional treatment of the mother during pregnancy 

61 v. Hippel. " Ueber die Haufigkeit von Gelenke-Erkrankungen bei Heredi- 
tar. Syphilitischen," Munch, mediz. Wochenschr., 1903. No. 31. 

62 Riehl. " Ueber den Einfluss der Behandlung syphiliskranker Mutter auf 
das Schicksal des Fotus." Wiener klin. Wochenschr., 1901, No. 26. Quot. by 
Vomer. 

63 Huguier. " De la maladie syphilitique sur les femmes enceintes et les 
nouvelles accouchees," 1841. 

64 Fonberg. " Einige statistische Daten uber Syphilis der Schwangeren mit 
Riicksicht auf Hereditat und Behandlung." Wien. mcd. Wochenschr., 1872, 
No. 22. 



278 THE MEDICAL ASPECTS 

for the purpose of saving the child from syphilis, during the first two 
years of the infection, has very little beneficial action. 

Discouraging facts are furnished by the statistics given by Albers- 
Schonberg, 65 from his experience in the Frier's Maternity in Leipsig. 
He reported eight cases of pregnant women in the condylomatous 
period of syphilis, who from the third to the sixth month of pregnancy 
had been treated with injections of mercury and potassium iodid. 
One of them had been infected three or four months before concep- 
tion, and was treated with mercurial inunctions. Of all, not one babe 
was born alive, and seven were entirely macerated. 

The stage of the luetic disease in the mother is considered by 
Werner 66 as the principal factor responsible for the death of the 
fetus. Indeed, concerning the prognosis on the result of the preg- 
nancy, he asserted that the more recent the syphilis is in the mother, 
the more serious the prospects are for the life of the babe. On the 
other hand, the less the maternal lues has been treated, the more 
deleterious influence it has by far on the offspring, as stated by Le 
Grand. 67 

For a conclusive result it is necessary to take under consideration 
two principal elements, the history of the mother and the observation 
of the child. The observation of the child must not be limited to the 
time of the birth, but must be continued during his first year, and 
probably until puberty. 

Observations have been taken by Werner amongst the infected 
prostitutes who are kept under police control, and when pregnant are 
noted and watched. From the observations of Sperk, 68 it clearly ap- 
pears that the first year of luetic infection is the most dangerous period 
for the production of an abortion. In the same way the first year of 
life is the most dangerous for a tainted child, for when the first year 
has passed the organism has gained sufficient strength to oppose the 
deleterious influence of the luetic germs. 

For this reason, in Hamburg there has been introduced the law 
that when a syphilitic prostitute leaves the hospital after her delivery, 
she has to take her babe every two weeks to the police physician for 
examination. When the child is found sick, it is immediately sent to 

65 Albers-Schonberg. " Ueber fotale Syphilis." Munch, med. Wochenshcr., 
1890. No. 19. 

66 Werner, S. " Ueber die Sterblichkeit und die Haufigkeit der hereditaren 
Syphilis bei den Kinder der Prostitnirten." Monatshefte f. prakt. Derm., Bd. 
xxiv, 1897, p. 183. 

67 Le Grand. " Syphilis als Ursache von Abortus." These de Paris. Ref. 
Wien. Med. Wochensch., 1890, No. 34. 

6S Sperk. " Theorie der Morbiditats und Mortalitats Statistik und ihre 
Anwendung zur Untersuchung der Prostituirten und Syphilitischen." Vier- 
teljahreschr. f. Derm, und Syphilis, 1886. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 279 

the hospital. These visits have to be continued for one year, so that the 
babe for one year remains under medical supervision. This rule has 
proved to be of great advantage to the babe, which is better taken care 
of. Although the mother returns to her shameless life, the babe is 
given to a family or to an institution to be cared for. In case a low 
prostitute tries by maltreatments to rid herself of her offspring, the 
babe is taken from her by the police and cared for in a public institu- 
tion. In fact, when the police physician has seen the babe healthy and 
well, and two weeks after it comes back very emaciated and seriously 
sick, or the death certificate is shown, this is already suspicious and 
may form a subject for inquest. 

In general the authors who have written on the statistics of the 
mortality of the offspring of recently infected mothers, admit that it 
amounts to eighty per cent. It is, however, very difficult to state what 
is the fate of the twenty per cent, still remaining. It is widely con- 
ceded that pregnancies amongst prostitutes are not frequent. The 
young prostitute is soon infected with gonorrhea, which produces 
endometritis and salpingitis, with occlusion of the abdominal ostium. 
This conclusion of the prevented conception on account of affection 
of the tubes, is somewhat preposterous, from the fact that in our hos- 
pital experience quite often prostitutes from the venereal ward have 
to be transferred to the obstetrical. 

Neither is it to be maintained that all prostitutes are syphilitic. 
Lesser said that every prostitute will be infected with syphilis, especially 
in the beginning of their career. Wwedensky 69 maintains that most 
prostitutes are infected with syphilis in the first three years after their 
registration, and that after five years all are infected. Raff, however, 
in reference to the statistics of the tertiary syphilis, states that he has 
found quite a number of puellce in whom neither as far as their history 
nor their physical condition was concerned, could be found traces of 
syphilis. In consequence, he says, that the statement that all pros- 
titutes are syphilitic is hypothetical. They are certainly in continuous 
danger of infection, but according to our experience in our venereal 
ward quite a number escape infection, at least for some years. 

Werner in referring to his interesting statistics taken from the 
prostitutes in Hamburg, registered 185 mothers with 243 children. 
Of the 185 mothers, 53 were not syphilitic. Afterwards, while under 
surveyance, 29 acquired syphilis, and 24 were still free from infection. 

It must be remarked that mortality among the children of the pros- 
titutes, although not infected with syphilis, is always rather high, so 
much so that of 51 children born of non-infected mothers, 29 died. 57 

69 Wwedensky. " Syphilis nnter den Prostituirten der St. Petersburger 
Bordelle." Arch. f. Derm. u. Syph., Bd. 36, Heft 1 und 2, Aug., 1896. 



280 THE MEDICAL ASPECTS 

per cent. ; while of 167 children, the mothers of whom had syphilis, 106, 
or 63.5 per cent., died. In one set of the statistics of Fournier, of the 
same number of children, 167, born of syphilitic prostitutes, 145 died, 
giving a total of 87 per cent. 

Of 167 children born of mothers who had suffered with syphilis, 
90 remained free from hereditary lues, 53.9 per cent., while yy, 46.1 
per cent, showed symptoms of congenital syphilis. Of the first 90, 46 
died, 51 per cent., while of the last yy, 60 died, 78 per cent. 

In reference to the influence of an early treatment on the health 
of the fetus, Werner 70 brings the statistics of 43 mothers, of whom 25 
were suffering with syphilis acquired from one to two years before, 9 
from three years, 7 had been infected for more than four years, and 
4 had the infection for a still longer time. Thirty-four of these 
women were subjected to treatment during pregnancy. They gave 
birth to 21 children with symptoms of hereditary lues and 13 were 
healthy. Of the luetic children after the first year, only 2 were still 
living, and of the others, 8 still remained. This showed a mortality 
of 71 per cent, with a morbidity of yy per cent. 

Vomer 71 reported nine cases of syphilitic women, treated during 
pregnancy, with the result of four luetic and five healthy children. 
The disease, however, was not between the first and second year from 
infection, but in some was of more remote occurrence, which may 
have had a favorable influence on the health of their babies. 

Seitz 72 reported his observations of eleven women who had been 
infected during pregnancy, or in the first part of their pregnancy. 
Eight had been treated with mercurial inunctions, or with injections 
with calomel, or peptonate of mercury. Six of them had abortions 
with macerated fetus, two had living babies, of which one luetic died a 
short time after birth, the other remained healthy. In twelve more 
cases of pregnancies in women who had been infected from one to two 
years before conception, eight had received the same specific treatment ; 
the result was five still-births with macerated fetus, two living fetuses 
before full term, and one healthy babe. Taking together the sixteen 
cases treated, they have given only two healthy babies, showing abor- 
tions 81 per cent., mortality 73 per cent, and morbidity, 87.5 per cent. 

Vomer offers statistics of pregnant women who had been infected 
from one to two years before conception or in the first four months 
of their pregnancy. During pregnancy all have shown eruptive 

70 Fournier, A. " Les families heredo-syphilitiques." Gaz. des Hop., 1892. 
Quoted by Werner, 1. c. 

71 Vomer, H. " Ueber die Vaginale specifische Behandlung schwangerer 
Frauen." Derm. Zeitschr. Bd. xi, 1904, p. 162. 

72 Seitz. " Einige statistische Angaben iiber den Einfluss der Lues auf der 
Verlauf der Schwangerschaft." Inaug. Dissert. Miinchen, 1898. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 281 

symptoms of more or less severity, with the prospects of congenital 
syphilis for the babe. Every one was subjected to general constitu- 
tional treatment of from four to six weeks with inunctions of unguent 
cinereum, or injections with bicyanate of mercury. 

After the general treatment, Vomer uses the vaginal treatment. 
The ordinary unguentum cinereum is incorporated with an equal 
quantity of sebum ovile, so as to give a strength of twelve per cent, 
and some consistency to make a suppository, which is easily introduced 
into the vagina and placed in contact with the cervix uteri. The 
vaginal treatment was used at various periods of the pregnancy, but 
from the results obtained, it seems that between the fifth and sixth 
months is the most appropriate time. 

Vomer produces the records of eleven syphilitic women who had 
been subjected to a constitutional treatment either by inunctions or by 
injections before conception, and after a while at the due time of 
pregnancy, were treated with vaginal mercurial suppositories. Of 
these women, one had a miscarriage at the end of the second month, 
another had a macerated fetus at about the end of the eighth month, 
a third had a babe in a good healthy condition somewhat prema- 
turely, which at the second month began to show signs of hereditary 
syphilis, coryza, papules, and four weeks later died. The others were 
delivered of normally healthy children, without specific signs. In the 
fourth week one babe showed symptoms of syphilis, and in the fifth 
week one became sick with pneumonia and died. Another babe, who 
had never shown signs of lues, died with gastro-enteritis. Two other 
babies towards the third month showed signs of lues ; both died, one 
the seventh month with gastro-enteritis, the other at the eighth month 
with padatrophia. Another died at ten months old with pneumonia ; 
the babe had never shown signs of syphilis, neither were signs of 
syphilis found at the autopsy. 

Eleven children remained alive ; a luetic one who, during the third 
month had suffered with mucous patches and with pustular eruption. 
was better, but was lost sight of. A second one, until after the fifth 
month, had been healthy and was seen no more. A third one showed 
a papulo-squamous eruption and a specific onychogryphosis. Four 
showed no sign of lues. The others suffered with some maculo- 
papular exanthema after the second and the third months. They 
stood the treatment and all got well. 

With these statistics Vomer shows that amongst 40 syphilitic 
women 36 had their delivery at full term, and only 4 had a miscar- 
riage or a still-birth, which means 10 per cent., and of the 4 two fetuses 
only showed signs of death from syphilis, which would cut down the 
rate to 5 per cent. 



282 THE MEDICAL ASPECTS 

These statistics show very encouraging results, when compared 
with those of other authors. Fournier 73 from his private practice 
found that in 39 cases only 50 per cent, had reached the full term of 
pregnancy, and of children born dead, 37, 48 per cent. From his 
hospital practice, in 167 cases, 79 cases, 47 per cent., were delivered at 
the full term, and 87 cases, 52 per cent., gave birth to dead children. 
Mewis 74 in 63 deliveries, calculates 58.7 per cent, at full term, and 2J 
per cent, still-births. Neumann 75 with 52 cases, shows 62 per cent, 
did not reach the normal time, and 38 per cent., dead fetuses. Pick 76 
and Fonberg 77 in 22 cases, show 50 per cent, premature births and 45 
per cent, dead babies. Seitz 7S in 17 cases, reports 20 per cent, pre- 
mature births, and 67 per cent, babies born dead. 

This would clearly show the vaginal treatment of syphilitic preg- 
nant women to be of a great benefit for the babe. 

In fact, the statistics of Vomer for 36 babies show that in the 
first three months six died, 22 per cent. Of. the remaining 30, three 
died between the fourth and fifth month, increasing the mortality to 
39 per cent. Two died between the seventh and eighth months, one in 
the tenth month; the mortality reaching 55 per cent, in the first nine 
months and 58 per cent, for the first year. 

It is necessary to note that in those children the cause of death 
was not always syphilis. In seven cases it was the result of gastro- 
enteritis ; in three cases syphilis caused the death of the babies as 
padatrophy ; the other deaths were caused, some by pneumonia and 
tuberculosis, while one died from furunculosis, and one from the con- 
sequence of prolonged labor. The time of their mortality was between 
the second and the fourth months. 

Only two babies were born dead, showing symptoms of syphilis, 
whereas the others at their birth were free from syphilitic manifesta- 
tions. One showed symptoms of lues between the second and the 
fourth week, while the others had syphilitic symptoms, five in the sec- 
ond month, eight in the third, four in the fourth, and only one in the 
eighth month. Most of the babies were affected between the second 
and the fourth months. The most common of the eruptions was the 

73 Fournier, A. " Syphilis et Mariage." 

74 Mewis. " Ueber Schwangerschaften, Geburt und Wochenbett Syphil- 
itischer, nebst Anhang iiber Syphilis congenita." Zeitsschr. f. Geb. u. Gyn., Stutt- 
gart, 1879. Quot. by Vomer. 

. 75 Neumann, I. " Klinische Studien zur Lehre von der congenitalen Syphi- 
lis," Me^d. Jahrb., Wien., 1885. 

76 Pick, F. J. " Zur Lehre von der hereditaren Syphilis." Wiener Medicinal 
Halle. 1863, IV, No. 11 und 12. 

77 Fonberg. " Einige statistische Daten iiber Syphilis der Schwangeren mit 
Riicksicht auf Hereditat und Behandlung." Wiener Med. Wochenschr., 1872, 
No. 22. 

78 Seitz, I c. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 283 

papular in ten cases, maculo-papular squamous in character was found 
five times ; macular syphilide twice. Syphilitic coryza was present 
four times, three cases showed condylomata lata, and two had psoriasis 
palmaris and plantaris ; only once was pemphigus found, as was also 
the case with onychogryphosis and pustular eruption. 

Twelve children remained entirely free from syphilis, and of them 
seven died. Comparing the statistics of Fournier, Kassowitz, Werner 
and others, one sees that the treatment per vaginam of pregnant 
syphilitic women is of great help to the babe, not only diminishing 
the mortality, but also the morbidity. In the statistics above men- 
tioned, it must be considered that the cases were all from prostitutes 
and illegitimate children. Werner had already pointed out that their 
mortality is far greater than that of the legitimate babies, although 
born of non 7 syphilitic mothers. Indeed, the mrwelcome visit of an 
illegitimate babe to the prostitute is rather troublesome in their calling. 
In their dissipated life, frequent abuse of alcoholics, excesses in coitus, 
emotions, pathemata, quarrels, all these together may contribute to 
cause abortion. After the babe is born, on account of the trouble and 
of the impediment it is to their calling, it may be greatly neglected, 
either purposely or not, so that they may get rid of their babe. 

In our experience we recall with pleasure many cases of syphilitic 
women who hai^e been subjected to specific treatment during their 
pregnancy, and have given birth to healthy children. We have already 
referred on different occasions to several syphilitic couples. As long 
as they remained without treatment, their pregnancies had as a result, 
dead babies or babies who died a few days after birth ; while, when 
they were subjected to a regular treatment, they gave birth to healthy 
children. 

Some years ago a gentleman called on us to see what was the 
trouble from which he was suffering. We found mucous patches of 
the tonsils and of the lips, with general adenopathy. Our diagnosis 
was that of secondary syphilis. This surprised our patient a great deal, 
for the reason that his physician had declared him perfectly cured of 
syphilis, and on this assurance he got married. We requested him to 
let us see his wife, who, he had already stated, was not well. The lady 
had a mild syphilitic roseola, with a few patches of the mucous 
membrane of the mouth. 

Both were subjected to gray oil injections, and after a while to 
mercurial inunctions. A few months afterwards she became pregnant. 
Treatment was continued intermittently during the whole time of her 
pregnancy. She was delivered at full term of a male babe, perfectly 
healthy. After the second month the babe showed a mild maculo- 
papular eruption, with a mild coryza. The babe was treated with 



284 . THE MEDICAL ASPECTS 

sublimate bath and calomel powders, 1-5 gr. each, twice a day. The 
symptoms disappeared, the babe was well, and although the mother 
suffered with suppurated mastitis, and he was deprived of the mother's 
milk, yet he continued to grow in weight. He is at present a bright 
boy five years old, healthy and intelligent, and has never shown any 
symptoms of syphilis since. One year later the mother was in the 
familyway again, two years and six months after syphilitic infection. 
When she discovered her condition, she subjected herself to specific 
treatment, which was intermittently continued until the eighth month 
of pregnancy. She was delivered at the full term of a healthy male 
babe, who has never shown any sign of syphilitic taint. The lady died 
this year with pulmonary tuberculosis. Both children so far are in 
excellent health. 

We are at present watching two pregnant ladies, one infected five 
years ago, who has had four miscarriages, and another infected two 
years since. Both have received twelve and fifteen injections with 
gray oil, and potassium iodid. During pregnancy both have used 
vaginal suppositories of twelve per cent, unguent hydrarg. The first 
has been a failure, on November 18 having given birth to a dead male 
babe, well developed, but macerated ; the epidermis was detached in 
large shreds. The placenta, with yellowish small foci, flabby and ir- 
regularly developed, showed signs of syphilitic placentitis. The sec- 
ond, on February, 1905, gave birth to a healthy babe, who so tar has 
shown no signs of lues. 

We can conclude this chapter with the assertion that the influence 
of the treatment of the syphilitic mother on the fetus is wonderful, and 
that treatment only is the true prophylactic measure which is capable 
of diminishing the ravages of the saddest inheritance which a careless 
syphilitic father can give to his unfortunate family. 

RETARDED HEREDITARY SYPHILIS 

From several observations mentioned above in reference to syphi- 
litic taint, possibly transmitted by heredity, paternal, maternal, or even 
both, it is plain that a babe born perfectly healthy may grow steadily 
and remain in good health until at a certain age it shows signs of 
syphilitic infection. This is what has been called syphilis hereditaria 
tarda, which may become manifest at any age from the fifth to the 
twentieth, or even thirtieth year of life. It was formerly a belief that 
syphilis was manifest at birth or a few weeks later, but this idea has 
been easily dispelled by the current observations of the manifestations 
of syphilis delayed not only for months, but even for years. 

Some authors believe that retarded syphilis, when showing 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 285 

symptoms at a late period, is nothing else than a reproduction of mild 
symptoms which very likely had passed unobserved during infancy. 
Sturgis 79 does not believe that syphilis can remain latent for so long 
a period of years without showing symptoms during the earlier period 
of the child's life. The periods of life in which syphilis has the great- 
est tendency to show its presence in the tainted organism are at birth, 
at the time of puberty, and at the close of middle life. He believes, 
and it is possible, that when retarded syphilis makes its appearance at 
puberty, mild symptoms have existed in early infancy in the apparently 
healthy babe, but have escaped attention, or have been attributed to 
other causes. These symptoms after their disappearance leave no 
trace behind, and thus when the child later on in life presents indubit- 
able symptoms of hereditary syphilitic infection, they are considered as 
the first manifestations. 

Indeed, the long latency and the long intermission are difficult 
to explain, unless by admitting that the virus at the time of the nisus 
formativus was stored in some of the developing organs, where it has 
remained as a potentiality for many years, until it has found a way to 
show the deleterious influence in an organic system, or in some organ, 
or rather in some part of one. 

Symptoms of retarded syphilis belong to the tertiary kind ; they 
show a tendency to infiltration and proliferation in the affected tissues. 
They occur in tainted persons, and the influence of a specific treatment 
in the earlier period of life seems to have no special effect. 

It is interesting to note that there is some disproportion between 
the sexes in the later forms of manifestations of inherited syphilis. 
Hutchinson 80 collected a series of cases of late syphilis in which it 
appears that in 23 cases of infantile iritis, 18 were females, and in 102 
cases of keratitis, 64 were in females. In the same way, of 21 cases of 
deafness, 15 were females. This gives a proportion of two to one, 
being 97 females and 47 males. Hutchinson explains these results by 
the fact that male infants affected with congenital syphilis are more 
prone to die than females, who seem better able to resist the action of 
the virus. 

It is an established fact that those who have inherited syphilis 
are liable to be affected with a peculiar form of inflammation of the 
cornea. The old ophthalmic surgeons had described a form of 
scrofulous corneitis which affects both eyes, which is of transitory 
duration and usually leaves no stains. It is a peculiar form of inter- 
stitial keratitis, which, according to Hutchinson, is a proof that the 
patient is tainted with inherited syphilis. He considers this chronic 

79 Sturgis, F. R. " A System of Gen. Urin. Dis." 1893, p. 633. 

80 Hutchinson, J. Twentieth Century Practice. Vol. xviii, p. 382. 



286 THE MEDICAL ASPECTS 

affection of the cornea as a revealing symptom of the later stages of 
inherited syphilis. 

Interstitial keratitis is not a secondary affection of infancy, but 
occurs at the time of adolescence or even in adult life, alone or pre- 
ceded by troubles in the joints as a characteristic sign of inherited taint. 
The persons affected have enjoyed good health, have never shown any 
suspicious symptoms of inherited syphilis, and all at once have had 
their eyes become inflamed. It lasts for a few months, then disappears 
without any tendency to relapse. 

Individuals affected with this disease may show some peculiar 
malformation or bad implantation, especially of the upper incisor teeth ; 
a malformation of the teeth which has been so well described by Hutch- 
inson and is generally known as Hutchinson's teeth. It consists in 
single vertical notches at the edge of the teeth, which constitute an 
evidence of atrophy of the middle tentacle, and as a consequence the 
tooth shrinks and remains narrow and also somewhat. short. In some 
other cases the teeth have a normal shape, the enamel, however, at 
the edge of the incisors is so damaged that it has taken on a rough, 
chalky appearance. These conditions of the teeth are at times so pro- 
nounced as to leave no doubt of the existence of syphilitic taint, while 
at other times they give only a suspicion, which needs corroboration. 

Interstitial keratitis of inherited syphilis begins with an irritability 
of the eyes, which causes them to water, and the corneae show small 
whitish patches, or small cloudy points. These gradually increase in 
size and spread until the whole cornea has acquired a partial opacity, 
recalling the opacity of ground glass. Congestion of the ciliary region 
takes place, and the conjunctiva, which to a certain extent is involved, 
shows a marked contrast with the condition of the cornea. In the 
early stages, on the margin of the corneal surface, there may be found 
small crescentic patches of congestion, which recall the tint of the 
salmon. These may gradually spread over the whole cornea, giving 
it a deep brownish purple color. This condition of the cornea forms 
a marked contrast with the comparatively pale conjunctiva which sur- 
rounds it. Pronounced photophobia accompanies the disease when at 
its height, so much so that the patient is nearly blind. The symptoms, 
however, begin to subside and the inflammatory phenomena decline; 
this is considered the third stage of the disease, the stage of reparation. 
It is a splendid illustration of the power of reparation, because a cornea 
which was entirely opaque and which would have given very little 
hope of restoration, may gradually clear up and be restored to its 
normal transparency. This process of reabsorption of the effused 
elements of the cornea may be complete in a few months, or may even 
require years. Hutchinson has recorded only two cases of interstitial 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 287 

keratitis where the cornea remained opaque, which he considers of 
rather rare occurrence. 

Complications on the part of the deep structure, such as the iris, 
choroid and retina may occur during the evolution of the keratitis, but 
only very rarely. The cornea alone suffers. If iritis occurs it is 
usually in a mild degree, and when the cornea is restored to its trans- 
parency, no impairment of the visual functions is left. This peculiar 
condition shows a great contrast with an iritis of secondary acquired 
syphilis, where the pupil is affected at an early period. 

In some cases of retarded syphilis there has been observed a con- 
dition of the retina closely resembling retinitis pigmentosa, and also 
an affection of the choroid, resembling choroiditis disseminata. Un- 
fortunately, these affections are rarely observed in their beginning, 
and when the patients ask for medical attendance, they are already 
beyond control. In this respect they are to be considered very in- 
sidious. It has been maintained by some authorities that keratitis is 
only a secondary affection arising from the choroidal disease. When 
the presence of choroidal changes can be detected, this is of valuable 
aid in the diagnosis. 

Deafness. — From the statistics of aural hospitals, it is clear that 
hereditary syphilis is greatly responsible for a large number of cases 
of deafness in young adults, which, if left to themselves, will become 
irremediable. Usually the affection is not limited to one ear, but both 
are affected. The affection does not come early like a form of a sec- 
ondary nature, but it makes its appearance late in life and may be 
compared with parenchymatous keratitis. In some cases, deafness 
begins with, or accompanies, or even follows an attack of keratitis. 
Its onset is rapid and insidious, because it is not attended by other 
symptoms, as no pain is present, only a slight dizziness. Loss of 
hearing is the dominant symptom, which so rapidly advances as to 
diminish considerably or even completely impair the sense of hearing. 
This condition is due to anatomo-pathological changes in the labyrinth, 
which have already been described by Toynbee, 81 Schwartze, 82 Vol- 
tolini, 83 Moos, 84 and Politzer. 85 In their dissections they have found 
results of infiltration and of a chronic inflammatory process in the 
delicate periosteal membrane between the bone and the nerve structure 
of the labyrinth. In the semi-circular canals they have also found 
small cell infiltration and an adhesion to the periosteum. One of the 
characteristic symptoms of syphilitic affection of the internal ear is 
the very rapid onset, which sometimes comes in one night, and the 

81 Toynbee. " Toynbee's Catalogue." No. 512. 
S2 Schwartze. Archiv fur Ohrenheilk., iv, p. 266. 

83 Voltolini. Virchow's Archiv, vol. xviii. 

84 Moos. Virchow's Archiv, vol. xix. 

85 Politzer. Archiv f. Ohrenheilk., xiv. 



288 THE MEDICAL ASPECTS 

accompanying vertigo. The deafness becomes nearly complete, so that 
the patient cannot hear a watch, voice or tuning-fork. In the begin- 
ning the bone conduction is diminished on one side more than on the 
other, and in this case the tuning-fork placed on the forehead is better 
heard in the better ear. 

There concurs, together with the symptoms above referred to, the 
loss of the acoustic perception of the higher notes, which in the begin- 
ning are heard as false or doubled. Roosa S6 has called this condition 
syphilitic cochlitis, because it is in this organ that the nerve fibers 
receive the impression of the musical sounds. In general we can say 
with Green 87 that it is difficult to localize the syphilitic affection in 
the cochlea alone, and on the dissecting table it has been found that the 
alterations were not limited to the cochlea, but that they involved the 
membranous vestibule, and the semicircular canals, thus the affection 
is better expressed by the name of syphilitic labyrinthitis. 

Brain. — In reference to retarded syphilitic manifestations of the 
brain, Ashby 88 referred to Jacksonian epilepsy as one of the earliest 
symptoms of syphilitic brain affection in retarded hereditarv syphilis, 
which usually occurs during the second year of life. The convulsions 
begin in one hand and become general after a while, and with their 
recurrence, increase in severity and in frequency. The affected arm 
becomes paretic and remains contracted. The same occurs in the leg 
of the opposite side, which remains paralyzed and contracted. The 
child gradually loses his intelligence and may lapse into idiocy. In 
some cases retarded syphilis is revealed as laryngismus, or spasmus 
glottidis. Ashby in the post-mortem of these cases found an extended 
softening of the brain from a different endoarteritis ; in some cases 
thick gelatinous masses were found at the base and in the convexity 
of the brain, limited in foci, and especially in the Fissura Sylvii sclerotic 
patches were present. 

It is to be remarked that there are cases of eclamptic fits associated 
with partial loss of consciousness, where their relation of syphilis is 
somewhat obscure. Indeed, in the autopsy of children who have died 
in an attack of convulsions, there have been found no alterations in the 
brain or in other organs. This led Dornbliith to the idea that the toxin 
of syphilis in the first two years of life is liable to produce attacks of 
eclampsia and of epilepsy, as well as different forms of mania, without 
showing material lesions of the brain. Ashby, however, doubts a 
great deal whether many of these cases are to be attributed to syphilis, 

86 Roosa. Trans, et Intern. Otolog. Congress. 1876. 

87 Green. J. O. " Syphilis of the Ear."' " A System of Gen. Urin. Dis.," etc., 
1903. 

88 Ashbv, H. " Gehirnerscheinungen bei congenitaler Syphilis" Edinburgh 
Congress, 1898. Ref. Derm. Zeitschr., Bd. v, 1898, p. 884. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 289 

and he denies the relation between syphilis and the meningitis posterior 
simplex of the brain, either acute or chronic, and he believes with 
Still that it is the result of a special micro-organism. 

Syphilis as an hereditary taint is not always the cause of ordinary 
infantile hemiplegia. Osier, in 180 cases of hemiplegia, claims only 
in one hereditary syphilis, while Hadden in 25 cases found 2 to be 
positively attributable to syphilis, and 11 with great probability. It 
must be considered that in the moment of the convulsions, a hemor- 
rhage may take place, which causes hemiplegia. We do not believe 
that all cases of convulsions are attributable to syphilitic taint, but 
when there is no other cause present, and when we see that the admin- 
istration of potassium iodid has a beneficial effect on the recurrence 
of the attacks, we have good grounds to believe them to be the result 
of syphilis. We can repeat the same remarks in relation to chronic 
hydrocephalus, which in many cases may be the result of other causes, 
but in some cases is without doubt produced by retarded hereditary 
syphilis. 

A little girl four years old presented a hydrocephalic head, and 
was at the same time somewhat queer in her actions. The general 
health was good, and the parents thought their child to be the picture 
of health. The mother, a young woman, had always been in good 
health. The father, an old man, advanced in the sixties, strong, claim- 
ing to have been always in good health, came to be treated for leg 
ulcers, which no physician had ever been able to cure. The ulcers 
were multiple, round, decidedly infiltrated, one of them involved the 
periosteum ; they were nothing else than ulcerated gummata. The 
application of emplastrum hydrargyri and the administration of 
potassium iodid brought the leg ulcers to a speedy recovery. This 
was for us a clear explanation of the hydrocephalus in his daughter. 

At the time of puberty paresis of the upper and lower extremities 
may occur, which is accompanied with eclamptic or choreiform 
motions, gradually the intelligence is blurred and idiocy is the end. 
In these cases syphilis is the cause, which may have shown in a mild 
form in infancy, or it may have left traces, such as notchy teeth, altera- 
tions in the shape of the nose, choroiditis, deafness, etc. In those 
cases the anatomo-pathologic lesions are those of a chronic meningo- 
encephalitis, with atrophy of the brain. There has been found a thick- 
ening of the dura, and sometimes a thickening and hardening of the 
bones of the skull, with constant and marked signs of syphilitic 
endarteritis. 

T. Telfort-Smith 89 referred to the relation of idiocy to syphilis, 

89 " Die Discussion iiber congenitale Syphilis auf dem Edinburger Kongress." 
Ref. Derm. Zeitschr., Bd. v, p. 887. 



290 THE MEDICAL ASPECTS 

and he believes that congenital idiocy is to be referred to syphilis, 
although no history and no signs would show its presence. The altera- 
tions induced by syphilis in the nervous system are sufficient explana- 
tion for the production of idiocy, and indeed we cannot consider any 
other cause so powerful for the destruction of the noblest of the human 
organs. We agree with J. Hutchinson, Jr., in his views that we 
cannot always find sure signs of syphilis. Indeed, the dystrophy of 
the teeth, the presence of interstitial keratitis, the attacks of osteo- 
arthritis, etc., which show positively the presence of hereditary syphilis, 
are missing in fifty per cent, of all cases of hereditary lues. In the 
other half we must suspect syphilis, which we recognize as the chief 
factor of degenerative processes of all anatomical systems. In heredi- 
tary syphilis it happens, as in acquired, that secondary symptoms are 
not observed at all, or at least are so mild as to escape detection, and 
then tertiary symptoms set in as deep proliferating and ulcerative 
forms. Very likely in some cases of hereditary lues, as we have al- 
ready mentioned, mild secondary symptoms have escaped the attention, 
and then late in life have reappeared as degenerative forms of the 
nervous system. 

Skin. — In retarded hereditary syphilis it is questionable whether 
we will find ulcerative processes of the skin, such as those which in 
bygone times were classed together with lupus, and diagnosed as lupus 
serpiginosus. We recollect the discussions about lupus scrofulosus 
and lupus syphiliticus, which to-day have been thoroughly settled and 
the diseases have been classed in their own nosological groups. We 
agree with Jonathan Hutchinson 90 that ulcerated gummata represent- 
ing lupus are more apt to occur in late acquired syphilis, rather than 
in retarded hereditary lues. In a case referred to by him, where 
mother and daughter were suffering with syphilis, the daughter ten 
years old had serpiginous ulcerations on her back. Although it looked 
like a case of inherited syphilis, yet he was able to ascertain that the 
girl had been infected in her infancy. He referred to a case reported 
by Bulkley, of a girl twenty-three years old, with notched teeth and 
with a well-marked history of hereditary syphilis, affected with 
ulcerated gummata of one of her arms, which had always been regarded 
as lupus. Specific treatment brought the affection to recovery, and 
it stood as a case of syphilitic ulcerated gummata from retarded heredi- 
tary syphilis. 

Phagedenic ulcers of the skin which are allied somewhat to lupus, 
are not infrequently found in tainted individuals. Hutchinson refers 
to rapid and destructive forms of ulceration, which are not attended 

90 Hutchinson, J. " Inherited Syphilis." Twentieth Cent. Pract., vol. xviii, 
p. 386. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



291 



by precedent infiltration or by the formation of tubercles. These 
phagedenic forms of ulceration occur on the face or in the throat, 
usually in children approaching the adolescent age. He describes these 
ulcers as of slow course, with ragged edges, as if they had been 
gnawed and undermined. The process is sufficiently rapid to destroy 
the soft palate and a part of the nose in a few months. 

When well treated and once healed up it never recurs. Hutchin- 
son referred to a case recorded by Percy Kidd, where a syphilitic 
ulceration due to inherited taint involved the larynx in a boy at the age 
of fourteen. He referred to another case presented by R. W. Parkes 
before the Pathological Society of London, in a boy of fifteen with 
nodes in his tibiae, who showed consequent stenosis of the bronchi and 
died with lung disease. 

To confirm his views, Hutchinson referred to another case of 
phagedenic ulcer from inherited syphilis, which was recorded by Harris 
and Simpson of Manchester. In a boy of fourteen, in whom the soft 
palate had been destroyed some years before, a process of phagedenic 
ulcer attacked his tongue in the middle, spreading towards the 
periphery and destroying nearly the whole of the organ. The boy 
showed no other indications of inherited syphilis, but his brother had 
the characteristic marks. 

In our experience we have seen phagedenic ulcers of the genitals, 
extending to the anus, in young prostitutes in the venereal wards of 
City Hospital. In some there were nodes of the tibiae, and unmistakable 
signs of inherited syphilis. In our case the phagedenic ulcer had 
affected the labia majora and minora, and had extended towards the 
pubis and the fossa crurogenitalis. In another case the ulcerative 
destruction had affected the perineum and the anus. The surface of 
the ulcers was covered with flabby, pale granulations which have 
never shown a tendency to heal up. In our cases it is difficult to say 
whether the phagedenic ulcer was the result of inherited syphilis mixed 
with tubercular diathesis, or whether it was the result of inherited 
syphilis with a new infection of acquired syphilis, syphilis binaria. 

One of our cases died with tubercular peritonitis. The peritoneum 
was found studded with tubercles. Another one, a colored girl, was 
very low with parenchymatous nephritis and the relatives took her 
away from the ward to their home. We have had no opportunity to 
see phagedenic ulcers of this kind of the face and throat from inherited 
syphilis. 

However, in our cases of phagedenic ulcers, the best results we 
have obtained have been from the local application of emplastrum 
hydrargyr. or dusting with iodoform, or bathing with bichlorid 1 per 
1000 solution, and from the internal use of iodides. 



292 THE MEDICAL ASPECTS 

Tongue. — Hutchinson referred to a case of gumma of the tongue, 
which had affected a woman of thirty-one, who had suffered with 
interstitial keratitis in her adolescence. In the family there was his- 
tory of syphilis. The gumma disappeared under the application of 
the iodides. It is about the only case of gumma of the tongue recorded 
as the result of inherited syphilis. 

We cannot add to this subject any personal observation, as we 
have seen gumma of the tongue only in cases of acquired syphilis. 

In speaking of the tongue, we find it wrong to attribute to in- 
herited syphilis that peculiar appearance of whitish rings on the 
tongues of children or boys, which was called ring-worm tongue, or 
better, geographic tongue. Parrot claimed this condition of the tongue 
to be due to specific origin. In our experience, we share the opinion 
of Hutchinson, that this affection is met with in other forms quite 
independent of syphilitic taint. We have met with cases of children 
and of adults showing whitish rings on the tongue, and we confess 
that they are rather suspicious signs of inherited syphilis. When, 
however, no precedents of syphilitic diathesis, or history of this disease 
in the family, are present, we will find this condition of the tongue to 
be produced by other causes. In one of our cases, a young lady of 
twenty-four, came to consult us for an enlargement of the sublingual 
glands. Our attention was called to her tongue, which showed rings 
covering the edges from the middle of the dorsum linguae to the apex. 
The rings were formed by edges somewhat elevated, whitish in color, 
and the mucosa comprehended in the ring was somewhat red, smooth 
and depressed. At first the case gave us the impression of a syphilitic 
tongue from inherited syphilis. Yet on studying more carefully the 
whole condition, we established our diagnosis of lupus erythematosus 
lingua. By repeated touching with pure lysol, the rings disappeared, 
the mucous membrane healed, and now there remain only whitish 
superficial scars in the center where the rings had been. The swell- 
ings of the sublingual glands have entirely disappeared. 

Bones. — We have already mentioned the frequency of late affec- 
tions of the bones and joints arising from hereditary syphilitic diathesis. 
The average of these diseases, according to Fournier and Hochsinger, 
would reach a total of forty per cent. It occurs in the form of 
periostitis with a tendency to produce roughness and hardness of the 
bones, especially on the tibiae. It is only rarely found on the bones 
forming the skull, and in the other long bones. This kind of periostitis 
while in progress is accompanied by much aching, but not by severe 
nocturnal pain. In some cases, fortunately rare, suppuration may be 
the result, accompanied by exfoliation of the superficial layers of the 
bone. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



293 



Hutchinson 91 refers to cases of atrophy of the long bones, as the 
result of chronic osteitis, which leads to great thickening of the affected 
bone with the production of a saber-shaped tibia, and after a while a 
condition of atrophy may follow. From skiagraphs taken from a 
syphilitic boy who had suffered fracture of the forearm, the radius 
showed itself to be greatly attenuated in its shaft and somewhat shorter 
than the ulna. 

There have been found affections of the bones in children with 
retarded hereditary syphilis which bear great resemblance to osteitis 
deformans on account of the thickening and distortion of the affected 
bones. Some of these cases of osteitis affect the epiphyses, as 
osteochondritis, causing immobility of the joint, a condition which was 
designated by Parrot as pseudoparalysis. It has nothing to do with 
the nervous system, but it is a local osteocondritis, which if not treated 
in time, may cause the destruction of the cartilages with irreparable 
damage of the joints. Quite often multiple affections of the joints 
are found as the result of hereditary syphilis in the form of an effu- 
sion in the serous membrane of the joints. Hydrarthrosis of both knees 
in adolescents is clearly a good example. Affections of the joints and 
bones of the spine, spondylitis, have been reported by Ridlon. 

Affections of bones and joints as results of retarded inherited 
syphilis are found in childhood and adolescence, but they are not met 
with after the twentieth year of life. 

Testes. — In acquired syphilis, gumma of the testis is a rather com- 
mon and well-marked form of lues, which may occur at various periods 
after the first onset of constitutional symptoms. In inherited syphilis, 
gumma of the testis may be found in the first few years of life. 
Henoch 92 referred to cases where the testicle was enlarged and hard, 
but painless. The infiltration occurs in the testis without involving 
the epididymus. In seven cases, four showed lesions of both testicles, 
and in three, only one was affected. It was found in children rang- 
ing in age between three months and two and one-half years. The 
infiltrating process commences around the arterioles of the testis, pro- 
ducing a cell formation and a general infiltration of the organ. The 
infiltration causes a pressure on the seminiferous tubules, which in con- 
sequence are strangulated and converted into a hard fibrous mass. 
When the infiltration is reabsorbed, the testicle remains in an atrophic 
condition. Fournier has noted several cases of atrophic condition of the 
testicle from inherited syphilis, some of which he referred to sclerotic 
atrophy, the consequence of infiltrated gumma, others to an arrest of 
development of the glands, which remain undeveloped as in infants. 

91 Hutchinson, J., /. c, p. 389. 

92 Henoch. Deutsche Zeitsch. f. prakt. Med., 1877. 



294 THE MEDICAL ASPECTS 

Arrest in the development of the generative organs has been 
observed quite frequently in connection with inherited syphilis, not only 
in the male, but also in the female. It has been found in the post- 
mortem of a case of this kind that the uterus and appendages were 
scarcely one-half of their normal size. 

Lymphatics and glands. — In our experience in all cases of heredi- 
tary syphilis in babies and children, the superficial glands of the cer- 
vical region, of the axillae and of the groins are felt under the exploring 
fingers as hard kernels. In some cases when the child improves and 
gets over the luetic condition, the glands are always found to be 
smaller. In some other cases they remain in the same condition of 
hardness, although the general health is good. In a family where the 
father has suffered a stroke of hemiplegia, the mother has had gum- 
mata, and in the beginning of their married life she had several abor- 
tions and still-born babies ; four girls born later, although small and 
very delicate, have never shown signs of syphilis. The lymphatic 
glands, however, have always been hard and perceptible as kernels 
under the exploring finger. We have charge of them as family physi- 
cian, and we often have occasion to see those girls, and a superficial 
examination of the cervical region reveals the same condition of the 
lymphatic glands. Sturgis 93 referred to the observations of Lam- 
auve 94 who remarked in children affected with congenital syphilis an 
engorgement of the lymphatics. He quotes Bertin 95 who described 
inguinal lymphangitis in children affected with inherited syphilis, when 
no other symptoms were present. The glands, hard and swollen, 
resembled scrofulous engorgement. Enlargement and swelling of 
lymphatic glands of the bronchi in a syphilitic child were found by 
Hutchinson. 96 Enlargement of the mesenteric glands were found by 
von Barensprung. 97 Enlargement of inguinal, prevertebral and medi- 
astinal glands were also found and described by Casati, Campana, 
Lancereaux, Rivington, and others. In all these cases the hyper- 
trophied glands had a grayish and yellow-white appearance, and under 
the microscope showed a thick cell infiltration, with some hypertrophy 
of their connective tissues. In no case was it found that a gland under- 
went suppuration. 

To the affected condition of the lymph-glands, and to the ravages 
in the spleen from congenital syphilis, we attribute the relatively 

93 Sturgis, F. R. " Hereditary Syphilis." " A System of Gen. Urin." etc., 
vol. ii. p. 645. 

94 Lamauve. " Traite des Maladies Syphilitiques des femmes en couche et 
des nouveau nes," 1804. 

95 Bertin. "Traite des Maladies Veneriennes chez les nouveau nes," 1810. 
90 Hutchinson, J. Medical J~imes and Gazette, 1858. 

97 Von Barensprung. " Die hereditare Syphilis," i860. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 295 

frequent occurrence of pseudoleukemia in heredosyphilitic children. 
One case came under our service in the Hospital, and we report it 
here on account of its interest : 

A boy of fourteen, whose mother died of stomach trouble, whose 
father was still suffering with ulcerated gummata of the legs, was 
brought to the institution by the police. He was complaining of 
pains in the legs, and was assigned by the visiting physician to Ward C 
as a syphilitic under our service. The boy, poorly developed, was 
greatly emaciated, his skin pale and of a sallow color, his mucous mem- 
branes nearly white. He complained of pains of both tibiae. The legs 
were swollen and edematous, the periosteum of the anterior portion of 
the tibia was infiltrated and tender to the touch. The lymph-glands of 
the whole body were enlarged, and those of the neck and groins could 
not only be felt by the exploring hand, but were visible to the eye. 
The spleen was enlarged and protruding under the ribs over five 
inches in the left hypochondrium. 

The urine was acid, specific gravity 1010, no albumin and no 
casts present. 

The examination of the blood gave the following result : 
September 16, 1903, a few days after admission, 

Reds 4,025,000 

Whites : . . . 15400 

Hemoglobin 80% 

Differential count of the whites, 

Small lymphocytes 94% 

Large lymphocytes 3% 

Polymorphonuclears 3% 

No eosinophiles. The reds showed nothing abnormal. 
Diagnosis was pseudoleukemia from congenital lues. 

He began his treatment with liquor VanSwieten, but after some 
days his condition being unchanged we gave gray oil injections, of 
five drops each, one every three days, and internally a saturated solu- 
tion of potassium iodid. The treatment was discontinued on account 
of stomatitis. The glands continued to increase. Then we resorted 
to the solution of Potass. Arsenit., which did not produce any im- 
provement. 

A second blood count gave October 10th, 

Reds 2,768.000 

Whites 6.600 

Hemoglobin 60% 



296 THE MEDICAL ASPECTS 

Differential count of the whites, 

Small lymphocytes 87% 

Large " 6% 

Polymorphonuclears 7% 

No eosinophiles. 

The reds showed characteristics of secondary anemia. 
The patient began to have fever of a remittent type, and for 
better attention and comfort was transferred to the medical service. 
Another blood examination November 10th gave, 

Reds 1 ,976,000 

Whites 17,800 

Hemoglobin 30% 

Differential count, 

Small lymphocytes 85% 

Large lymphocytes 10.6% 

Polymorphonuclears 3-3% 

The patient was constantly growing worse, and the relatives took 
him home. 

The history of the case shows that the alterations of the lymph- 
glands wrought by congenital syphilis are of a permanent nature, 
which, together with an altered condition of the spleen, often are the 
determining cause of leukemia. 

A boy in a private family died with leukemia. He was attended 
by a colleague, who took all possible care of him. Nobody had ever 
suspected the possibility of syphilis in the family. Some years after 
the father came to consult us for ulcers of the legs. They were 
ulcerated gummata, which under the mixed treatment and the local 
mercurial applications soon healed. Then we recalled the death of 
his son from leukemia, and we found the clew to explain the cause 
of the disease. 

In some cases, retarded inherited syphilis may lead to arrest of 
growth, and the patient remains a dwarf. It is assumed that in these 
cases the pituitary body has been the seat of the luetic attack. 

In reference to the question of the persistence of syphilitic taint 
in individuals who have received from their parents such a bad heritage, 
it is difficult to state any definite limit. Hutchinson referred to a case 
which was recorded by Hawthorne of a syphilitic family in which the 
eldest born, a female, was healthy in her infancy. At the age of 
twenty-three she suffered with keratitis. Her teeth were notchy and 
characteristic of inherited lues. Three pregnancies followed of which 
one resulted in a miscarriage, the others in the birth of two children, 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 297 

both of whom died of acute hydrocephalus. A fifth pregnancy pro- 
duced a boy who at the age of eighteen had characteristic notchy 
teeth, enlarged spleen and hemoglobinuria. From a sixth pregnancy 
a boy was born one year younger than the last one, who up to the 
age of seventeen remained in good health, robust and free from all 
evidences of taint. After this a stillborn male was produced. 

It is very difficult to explain how the syphilitic germ attacks one 
babe more than another ; respects one, and the next is killed or receives 
such deep lesions that it dies a short time afterwards. It is possible 
that the taint persisted in the mother's ovaries for the long period of 
seven years. It is also possible that the father received a second in- 
fection, which might be assumed from the saltatory way of transmission 
of lues in the children. 

From Hutchinson we take another interesting narrative in refer- 
ence to a syphilitic family, which was published by Dr. Routh, of 
Manchester. The mother had never ailed in any way, the father had 
shown no symptoms of syphilis since his marriage. After two still- 
births a child was born who in infancy showed symptoms of congenital 
lues, which under mercurial treatment subsided. At the age of nine 
the child had an enormous spleen and a nodular liver, with enlarge- 
ment of the glands, but no stigmata of syphilis. Specific treatment 
did not relieve the condition of her spleen and liver. The next child, 
two years younger, had infantile syphilitic manifestations, for which 
she was treated. At the age of seven she had the characteristic notchy 
teeth and rickets. A third child suffered slightly in his infancy, re- 
ceived no treatment, but at the age of two developed hemiplegia of 
the right side. Two children born somewhat later on were perfectly 
healthy and remained so. 

This is another illustration of the irregularity which we observe 
in the transmission of the hereditary luetic taint. More remarkable 
is the absolute freedom from symptoms of both parents, notwith- 
standing the persistence in the transmission of the taint. In all cases, 
however, we can clearly see the gradual dying out of the taint, although 
the patients have neglected treatment. 

LATENCY OF INHERITED SYPHILIS 

With all our best means for diagnostic purposes we can say 
that cases where syphilis has been inherited may pass entirely unob- 
served. We are greatly indebted to Hutchinson for calling the atten- 
tion of the practitioners to the malformation of the teeth and to the 
parenchymatous keratitis, which have revealed many cases where syph- 
ilis would never have been suspected. On the other side, we know 
that the notchy teeth and the keratitis will be found in only fifty per 



298 THE MEDICAL ASPECTS 

cent, of the cases of inherited syphilis, while other cases with clear 
manifestations will not show any sign in the teeth. This leads us to 
believe that a certain number of persons may have received the syph- 
ilitic taint by inheritance, but no specific occurrences have revealed its 
existence. We have already mentioned the opinion of our esteemed 
teacher, Sigmund v. Ilanor, who used to say that if syphilitic taint 
exists in one individual, if it does not show in his infancy, it will 
show in his adolescence or in his youth or still later, but the moment 
will come when he will show symptoms, or the effects of the dele- 
terious action of the lues. We can scarcely believe it possible that, 
when a child is born with syphilitic taint and shows no symptoms in 
infancy, there is any probability he will show any in later life. Hutch- 
inson stated that phenomena of tertiary lues are presumably for the 
most part recrudescences of what occurred in the secondary stage. 
We have, however, seen many cases where no secondary symptoms 
have occurred, and yet the tainted person has suffered severe symp- 
toms of a tertiary nature. 

In the tainted individual, besides the malformation of the teeth, 
there are always some features which give a characteristic physiog- 
nomy, such as a sunken nose, prominent forehead, prominent parietal 
eminences, detached auriculas, etc. These conditions, however, will 
only suggest the transmission of syphilis by heredity, but they will not 
be considered as convincing proof. 

An infant may have circulating in his system the virus of syphilis 
and yet show no symptoms. This has been unfortunately proved in 
the cases of inoculation of syphilis by vaccination, where a skillful 
physician had selected the infant as vaccinifer because it exhibited all 
the signs of perfect and vigorous health. In 1874 Hutchinson pub- 
lished a series of cases of the kind. One child had been selected as 
vaccinifer at a station as a specially healthy child. This conveyed 
syphilis to sixteen other children, and yet the first child remained 
apparently healthy. After the most minute and careful search there 
was found at the anus a small doubtful condyloma as the only visible 
symptoms of syphilitic infection. 

The presence of the syphilitic virus in the system does not neces- 
sarily arrest the growth of the child, or show upon the skin and 
mucous membranes. We have remarked, in treating of acquired syph- 
ilis, that many times persons infected go through the primary and 
secondary stage while retaining the appearance of good health, so 
much so that syphilis may pass unobserved. The same may occur in 
inherited syphilis. Here, however, we have the parental history, and 
also the syphilitic manifestations in other brothers or sisters, which 
may come to our assistance and confirm our suspicions. 






TRANSMISSION OF SYPHILIS TO THE OFFSPRING 299 

In some cases it may happen that we find amongst several brothers 
and sisters some showing symptoms of inherited lues, and others who 
have not shown and who do not show any manifestations whatever. 
It will be rather difficult to assume non-inheritance in those children, 
and we will consider them as only apparently free. The developing 
organism of the child tainted with lues gradually loses by its 
rapid metabolism the specific poison, so that a child having passed 
the dangerous period of infancy and entering adolescence, does not 
show other symptoms and regains good health. Children are usually 
treated w T hen showing secondary syphilitic manifestations, and as soon 
as they are over, treatment is dropped. Their recovery is therefore 
to be attributed rather to the rapidity of the metabolism, which frees 
the system from the syphilitic poison, than to the treatment applied. 
Inherited taint, however, may have some peculiar effect in the develop- 
ment of the anatomical systems, and especially the nervous system, 
which is revealed by true neuroses or by some difficulties in the edu- 
cation of the adolescent, or by some perverted tendencies. It is 
possible that no symptoms of lues will reveal its presence, that the 
germs will be eliminated, but its influence in the blood vessels has 
already produced faults or stigmata in the neuron, which will be 
revealed later on by moral extravagances, or by moral deformities, as 
we will see in the following chapters. 

SYPHILIS OF THE THIRD GENERATION 

The babe when it makes its appearance in this world must not 
be considered as an isolated being, but is a link of a long chain, the 
first link of which has been lost in the past. He carries with him all 
the peculiar characteristics, aptitudes, dispositions, impressions and 
tendencies which came to him from an atavistic influence, which he 
will after a while transmit to his descendants. When the offspring 
springs from a healthy and strong parentage, he will be strong and 
endowed with the characteristics of strength and health transmitted 
to him. But when the hereditary blemish of syphilitic infection is 
transmitted to him, quite often the most noble of all the systems, the 
nervous system, is affected in its organization, and sooner or later it 
will be revealed in the form of neuroses, or of some unnatural and 
extravagant defects of the mind, which make them belong to the 
class of " cranks," or degenerates. 

In consequence of hereditary syphilis we find some anomalies of 
development, or some peculiar marks, which in many cases can 
scarcely be considered as true pathological conditions, and are called 
dystrophias, which in most of the cases produce alterations of the 



300 



THE MEDICAL ASPECTS 



organs with impairment in their function. Whether certain defects 
shall prove injurious or not to the organism is determined: in some 
cases at the time of birth ; in others, during the development ; and in 
others, late in life. Under the influence of hereditary syphilis, on 
account of the defects produced in the vascular sphere, an organ, 
structure or function may be lacking or excessive. Embryonic poten- 
tialities are easily influenced by the developing syphilitic germ which 
affects organs and tissues, sometimes with a deviation of formation 
of essential elements resulting in monstrosities. The anomalies of 
development may be revealed in the affection of the different organs, 
as in the delicate structure of the brain. These variations may be 
found affecting the nervous system in its anatomical structure, and 
produce a true disease or a regress of the individual in the direction 
of degeneracy. In these cases the development of the neuron takes 
on successive changes, analogous to those found in adult fish, frogs, 
birds, etc. There is an increasing complexity of the cell but no 
formation of rudimentary parts, in consequence there is an arrest in 
the development of the neuron. The imperfect development of the 
neuron implies an imperfect power of association, and as a conse- 
quence an impaired facility for education. 

The peculiar anatomo-pathological alterations produced by syphilis 
in the tunics of the young, newly forming blood vessels, are sufficient 
to explain, at the period of formative stress, on account of the lack of 
nutrition the imperfect development of the delicate neuron. 

In the transmission of syphilis it may happen that the recently 
known spirochaetae, the cause of this disease, may attack the cerebral 
organs and act as factors of epilepsy in the sense maintained by 
Weisman. 98 In other cases, the malformation of the cells of the brain 
will be the cause of idiocy, or of other serious psycoses. At times 
it is revealed in the somatic development of different organs, and we 
find defective development of the urogenital system, deformities of 
the face, skull, irregular growth of the teeth, misshapen ears and 
limbs. These anomalies are sometimes associated with perversions of 
the mind, and in many cases the affected persons show unmistakable 
signs of syphilis. It is easy to understand that the nervous system 
has its part in the disorders of general development, since individuals 
who present deformities have also decided disorders of the nervous 
system. 

The inebriety in the father may have some influence in the de- 
veloping offspring, who may have neuroses of different kinds, but we 
have also histories of healthy children in spite of the drinking habits 
of the father. According to our observations, inherited syphilis must 
98 Weisman. " Essays on Heredity." Oxford, 1889. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



301 



be held accountable as the cause of the malformations and of the 
neuroses of the descendants. 

J. Hutchinson " in his wide experience with syphilitic families, 
is somewhat reticent in the matter of affirming that inherited syphilitic 
taint may be transmitted to the offspring. He finds that this point 
may have some support if we keep in mind the long persistence of 
the possibility of transmission by mothers. Another difficulty is that 
one or the other parent of the third generation infant may have had 
syphilis in acquired form. 

It is rather a complicated question and practically it is very 
difficult to follow the history of three generations, when it is a hard 
matter to find out the history of a single patient. Furthermore, the 
individual of the third generation must be followed, because some 
dystrophias are apparent at the time of the birth, but other conditions 
like the azoospermia, the rudimentary uterus, the hystero-epilepsia, the 
sexual perversions, cannot be found out other than at the time of 
puberty. 

In the preceding chapter we have seen that in children born of 
syphilitic parents there is found a certain immunity, which, however, 
is only limited to the first period of life. We have referred to some 
cases of our own practice tending to show that individuals with un- 
mistakable signs of hereditary syphilis are again infected with the 
disease, forming that which Tarnowski calls syphilis binaria, a sort of 
double syphilis, one inherited and the other acquired. This double 
infection has indeed a deteriorating influence on the whole system, 
which is revealed in the infected person and in his descendants, causing 
degeneration of the race. The double combination of syphilis causes 
deviation from the ordinary type of the evolution of the disease, 
which produces atypic forms, and as a double contamination will have 
a deteriorating influence on the descendants. Tarnowski refers to 
some very interesting statistics taken from twenty-five families, which 
have been constantly under his observation. Following the first, sec- 
ond and third generation, he finds that syphilis in the second genera- 
tion is already much milder, and causes less trouble than when 
recently acquired, and in the third generation is still much milder 
and less injurious than in the second. Amongst eighty-one indi- 
viduals of the third generation of syphilitic families, in two only 
were found signs of hereditary syphilis and in fourteen dystrophies. 

Tarnowski comes to the conclusion that when individuals in the 
third generation show symptoms of hereditary syphilis, this is mostly 
due to a new infection on the part of the party of the second genera- 
tion, or as he calls it syphilis binaria. Vice versa, an individual of 
09 Congres de Medicine, Paris, 1900. Section dc Dermatologie et de Syphilog, 



302 THE MEDICAL ASPECTS 

the second generation affected by hereditary syphilis, if he does not 
acquire syphilis again, will not transmit hereditary syphilis to his 
descendants of the third generation. Consequently acquired syphilis 
in the first generation does not reach the third generation in the 
ordinary way, nor in the saltatory way. It will never produce the 
ordinary symptoms of the syphilitic hereditary infection in the third 
generation, but the infection remains as a taint in the family. So far 
we are lacking in observations and in facts in order to establish what 
this syphilitic taint is capable of producing in the development of the 
offspring. 

Tarnowski refers to some statistical data, which are able to throw 
some light on so obscure a subject. 

In 25 syphilitic families he noted 155 pregnancies, which re- 
sulted in 

Living children, 98 ) 

Still births, 57 \ second generation. 

Of the 98 born living children, 40 got married, and they produced 
131 pregnancies, resulting in 



Stillbirths, 41 
Living children, 91 



I third generation. 



These results have a tendency to show that syphilis has much more 
deleterious effects on the second generation, and as hereditary syphilis, 
is less pernicious on the third generation. 

In fact, of the 98 children of the second generation, Tarnowski 
could account for 91, of whom 49 per cent, showed symptoms of 
hereditary lues, also different dystrophies. While of the 81 living 
children belonging to the third generation, only 19.7 per cent, showed 
symptoms or dystrophies accountable to lues. 

The symptoms and dystrophies consisted in 91 cases of the second 
generation, 12 in manifestations of hereditary lues, and 33 dystrophies. 
In the 81 cases belonging to the third generation, only twice could he 
find symptoms of hereditary syphilis, and 14 times cases of dystrophies. 

In regard to the third generation, Tarnowski maintains that 
hereditary luetic symptoms are to be attributed rather to syphilis 
binaria, than to the transmission of syphilis from the first generation. 
When a party of the second generation has remained exempt from 
another infection, although he has shown symptoms of hereditary 
syphilis, he will not transmit syphilis to his descendants of the third 
generation. 

These observations, however, are not in accordance with those 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 303 

reported by De Amicis 10 ° who in five syphilitic families found heredi- 
tary syphilis to be just as virulent in the third generation as in the 
second. In fact, in the first case of the second generation, one boy 
lived with symptoms of hereditary syphilis, and a girl died in the first 
year with meningitis. 

The boy of the second generation during his life suffered gonar- 
tritis and at the age of twenty had parenchymatous keratitis. At the 
age of twenty-six he married a healthy girl, and the result of their 
marriage was : 

First pregnancy, male child, stillborn. 

Second pregnancy, male, living-, affected with hydrocephalus. 

Third pregnancy, female, died ten months old from meningitis. 

Fourth pregnancy, male, living, showing microcephalism. 
Second family : 

First generation. Man affected with syphilis married a healthy 
woman, and four children were the result of this marriage. Of the 
four children of the second generation, three males died in infancy, 
the last one, a female, was subjected to mercurial treatment and lived, 
though remaining very delicate. 

She married a healthy man, and as result in the third generation : 

First pregnancy, a female, who soon began to lose in nutrition, 
but was saved by mercurial treatment. 

Second pregnancy, female, living, died with intestinal affection in 
the twenty-sixth month of life. 

Third pregnancy, male, living now, eleven months old, now under 
specific treatment. 
Third family : 

Man affected with syphilis married a healthy woman. Result in 
second generation: 

First pregnancy, female, at the age of thirteen suffered with 
parenchymatous keratitis and cervical adenopathy. In consequence 
of mercurial treatment recovered. She married a young man free 
from syphilis, with the result in the third generation of: 

First pregnancy, abortion in fifth month. 
Fourth family: 

Man affected with syphilis after good treatment married a healthy 
woman. Second generation : 

First pregnancy, living child. 

Second pregnancy, living child. 

Third pregnancy, abortion. 

Fourth pregnancy, abortion. 

100 De Amicis, T. "La discendenza degli eredosifilitici." Giont. Intern. 
delle Scienze Mediche. Anno xxiii. 



304 THE MEDICAL ASPECTS 

Fifth pregnancy, abortion. 

Third generation : The first son, who never showed syphilitic 
manifestations, at the age of twenty-two married a healthy woman 
with the following results : 

First pregnancy, male, died thirteen months old. 

Second pregnancy, male, died fifteen months old with spasms. 

Third pregnancy, male, died two months old. 

Fourth pregnancy, female, living, when two years old pronounced 
only Papa and Mamma. She had whooping-cough, and after it she 
did not pronounce a word. Now, at the age of seven she is deaf, she 
has microcephalism and has a tendency to idiocy. 
Fifth family:- 

First generation has some obscure history. 

Second generation : Son shows multiple scars on the chest and 
on the limbs, from lesions suffered in his infancy. He has kyphosis, 
and a sister died from hydrocephalus. No history of tuberculosis in 
the family, and the cutaneous lesions cannot find any other explanation 
than that of congenital syphilis. 

He is the third of the family. His brother died at the age of 
two. He married a healthy woman, with the following results in the 
third generation : 

First pregnancy, abortion at the seventh month. 

Second pregnancy, abortion at the seventh month. 

Third pregnancy, abortion at the seventh month. 
Fourth pregnancy, \ 

Fifth pregnancy, v premature delivery, babies died after a few days. 
Sixth pregnancy, ) 

Seventh pregnancy, living babe, died five minutes after birth. 

Eighth pregnancy, abortion third month. 

We have purposely referred to the statistics of De Amicis, be- 
cause they show that syphilis in the third generation has maintained 
its virulent and fatal effect on the developing offspring. His observa- 
tions recall those of Jullien, who reported cases of syphilitic mani- 
festations with virulent symptoms as the results of syphilitic heredity 
in the third generation, and also those of Barthelemy and Pospelow, 
who found true gummatous productions, which are manifestations 
of genuine late syphilis. 

These virulent forms of syphilis transmitted, to the third genera- 
tion are those which Tarnowski explains as the result of syphilis 
binaria. It is interesting to recollect his observations, which give a 
different color to the dark background which syphilis gives when 
transmitted to the third generation. In the observations of the authors 
referred to and in those of De Amicis it seems that no reinfection had 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



305 






taken place and that the lesions which were found in the third genera- 
tion were to be attributed directly to syphilis of the first generation. 
In these cases the lesions could be referred to inflammatory luetic 
processes, to gummatous infiltrations of the skin, bones and different 
organs, together with abortions and stillborn babies. 

Indeed, it seems that syphilis coming from the first generation 
has lost very little of its virulence, so far as it concerns the third 
generation. Edmund Fournier has referred to the statistics of 46 
married couples of heredo-syphilitics, who produced 146 pregnancies, 
with the results of 43 abortions, 37 babies born dead or died soon 
after birth, while 65 children were still living. Of the 65 living chil- 
dren many were affected with deformities, anomalies of development, 
dystrophies, such as to make them a class of unhappy invalids. In 
the statistics of Jullien on 256 pregnancies, there were 77 between 
abortions and stillbirths, which is 30 per cent. 

The reason of so great a mortality of these children is easily 
found in their weak constitution, which causes their life to be severely 
menaced, especially in the first months of their existence. 

When growing adolescents, they, on account of the weak systemic 
condition, are liable to show neuroses, meningitis, eclampsia, and 
are more easily affected by the other ordinary morbific causes. 

When adults, they often suffer from epilepsy, neurotic conditions, 
idiotism. Sometimes they have affections of the bones. They have 
something peculiar about their faces; the frontal eminences are quite 
accentuated, the features are asymetric, the nose saddle-shaped. The 
alterations of their physiognomy are often accompanied by deficient 
cerebral functions, so that they are unable to study, to work, some- 
times they have trouble in their speech, and they are often deaf and 
dumb. 

The dystrophic conditions of the teeth which are found as the 
result of hereditary syphilis in the second generation, are found in 
the third also. 

In the heredo-syphilitics there have been found peculiar stigmata 
in the fundus oculi, which according to Galezowski and to Albert 
Antonelli 101 bear witness to hereditary syphilis. The principal troubles 
are found in disturbances of the pigment of the fundus oculi, oftener 
of the choroides, which are not different from those which are seen 
in acquired syphilis after the recovery from a syphilitic choroiditis. 
The parents of the patient in question had no signs of acquired 
syphilis, and had only shown traces of syphilitic taint. 

According to the same Antonelli, syphilis in the third generation 

101 Antonelli, A. Quoted by De Amicis, 1. c. 



306 THE MEDICAL ASPECTS 

is the cause of optic neuritis, or neuro-retinitis, and chorio-retimtis, 
a process which occurs during fetal life or in the beginning of the 
extra-uterine life, and only rarely during infancy. These processes 
of the fundus oculi from heredo-syphilitic taint are usually mild, 
especially when the intensity of the virus has been so greatly attenu- 
ated as to produce only an hereditary syphilis without any apparent 
symptoms. They may, however, leave abnormal pigmentations and 
superficial scars, which are visible with the ophthalmoscope, and re- 
main as characteristic stigmata of an hereditary taint. 

The same condition, however, is found in heredo-syphilitic patients 
of the second generation, and the difference between the second and 
third generation consists only in a milder form for the third genera- 
tion, showing the attenuation of the syphilitic taint. 

This pigmented condition of the fundus oculi and the difference 
of intensity between tainted individuals of the second and third genera- 
tion is a witness of the influence of the first heredity on the second 
and can be considered together with other important alterations and 
dystrophies. 

The comparative study of the dystrophies of the second and 
third generation in the same families confirms the observations of 
Tarnowski of the gradual diminution of the intensity of syphilis from 
one to the other generation. 

In the second and third generation dystrophies are frequently 
found in the teeth, and also in the shape of the auriculae. Often in 
the second generation, the teeth appear notchy, teeth of Hutchinson, 
or in the form of microdentism, or by congenital 'absence of the 
superior lateral incisors ; while in the third generation they will appear 
only as erosions of the teeth or as an anomalous implantation, or as 
premature decay of the teeth. 

The auriculae of the second generation are often badly shaped 
as in the form described by Morel, or show absolute deformity. In 
the third generation these deformities are not reproduced unless in 
the direction of the auriculae. Dystrophies of a severe type in the 
second generation, such as infantilism, microcephaly, persistence of 
the foramen Botalli, lack of development ' of some parts, are usually 
not reproduced in the third generation. In the same way, congenital 
obesity, epilepsy, morbus Basedowi, are only very seldom found in 
the third generation. 

In reference to the generative organs, Tarnowski was able to find 
seven persons of the second generation out of seventy-four showing 
sexual dystrophies, which in the females consisted in rudimentary 
development of the uterus, and in men in azoospermia, impotency, 
and in two cases in sexual perversion. 



Plate XIV 




DlATROPHY OF THE FlNGERS IN A HeREDOSYPHILIDE 




Ulcerated Gum mat a in a Heredo-syphilide 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 307 

We give an illustration that shows a deformity of both hands, 
consisting in an anomaly of development of the fingers, giving an 
ugly appearance to the hands. It was in a patient nineteen years old 
in our service in the City Hospital, suffering with syphilitic periostitis 
of the tibiae from hereditary syphilis. 

In fact, all these dystrophies are accompanied by some symptoms 
which undoubtedly show syphilitic antecedents, such as notchy teeth, 
sinking of the base of the nose, natiform skull. These are such 
characteristic stigmata that they testify to the presence of syphilis in 
both, or at least in one, of the parents. But fortunately, as the genera- 
tions progress, the stigmata gradually disappear, so that if no new 
infection takes place in the second generation, signs of syphilis are 
nearly lost in the third generation, and in the fourth generation any 
taint of syphilis has been completely extinguished. 

We can see that syphilis has a great influence on the generations : 
in the second it is transmitted, producing death of the fetus as in 
miscarriages, or as infants born dead, or causing the babe to die 
during the first year of life ; it causes in some cases sterility of the 
individuals, and in many circumstances malformations, dystrophies of 
different degrees. 

Following the statistics given by Tarnowski we find that in the 
second generation only twenty-two per cent, have been entirely free 
from syphilitic symptoms, and have shown no signs of anatomical or 
functional dystrophies. In the third generation syphilis loses its morbid 
influence and fifty-five per cent, of the babies are born well without 
taint of the morbid inheritance from their parents. If no other un- 
favorable heredity takes place, the fourth generation returns to normal. 

The attenuation of the morbid influence of syphilis from genera- 
tion to generation is greatly influenced by a new infection, especially 
if this takes place in the second generation, and then as cases of 
syphilis binaria. In these cases in a family where one member already 
having hereditary syphilis acquires a new infection, the influence on 
the third generation is indeed very pernicious. From this double 
syphilis the number of miscarriages is greatly increased, as is also 
that of the children born dead or dying in the first year of life. The 
symptoms of hereditary syphilis in the third generation are then much 
more frequent, and the malformations and dystrophies likewise occur 
quite often, showing a much more powerful virulence than in the 
ordinary cases of hereditary syphilis. 

Fortunately, cases of syphilis binaria are rarely found, and the 
degeneration of syphilitic families is not often met with. Further- 
more, the marriage of members descending from syphilitic families 
to parties of healthy families exercises a curative effect on the health 



308 THE MEDICAL ASPECTS 

of the generations, so that in the fourth or fifth generation the families 
return to a normal healthy condition. 

This is the only explanation which can be given in regard to the 
existence of syphilis for so many centuries without causing diminution 
or degeneration in the population. In consequence we have all reason 
to maintain that the remedy against syphilis amongst the population 
will be easily found. The proper laws for regulating prostitution, the 
isolation of the infected parties, preventing them from spreading the 
infection, and laws regulating marriages, will give us the certainty 
of succeeding in stamping out this scourge of humanity. 

In the question of hereditary syphilis in the third generation, 
although many observations have been referred to, yet a great deal 
of doubt is found in the generality of the cases. It is, however, neces- 
sary to note a great difference in the origin of the heredity, whether 
from the mother or from the father. The infection from the mother 
is much more sure than from the father. In many cases in which we 
had treated the father for syphilis before his marriage, we have seen 
result a family of healthy children. We have also seen the father, 
affected with extensive patches of syphilis tuberculo-ulcerosa on his 
legs, have children with splendid health. But we always return to 
the assertion of Sigmund, when you have to do with a party born 
from a syphilitic parent, you must not consider him or her in his 
first youth, but you must follow him in all periods of life. When the 
mother has the infection then the transmission of syphilis to the off- 
spring is a certainty. 

Indeed, we find in our daily practice, and other practitioners, 
clinicians and specialists refer to having often met with cases where 
the morbid phenomena could not be explained in any other way than 
by the admission of a second hereditary transmission. Jullien 102 in 
this regard has collected a large number of observations, which have 
much enriched the doctrine of syphilitic heredity, and to which we 
must refer the reader for a complete knowledge on the subject. 

From all his observations it results that syphilis hereditaria, al- 
though in the third generation, is often the cause of abortion or of 
the death of the infant at the time of birth. Syphilitic heredity is 
not a cause of sterility, it has no influence on the phenomenon of 
conception, on the contrary, in syphilitic families we often find a 
number of children. Someone would attribute to a syphilitic taint 
the birth of two or three children at the same pregnancy, but so far 
there are only contradictory arguments on this point. 

Syphilitic lesions are referred to by different observers, some 

102 Jullien. " Descendance des heredo-syphilitiques." XIII Congres Intern, 
de Medicine, Paris, 1900. 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 309 

belonging to the secondary period, some to the tertiary. In conse- 
quence there have been found in some cases superficial eruptions of 
the skin, in others a deep destructive process of the same in the form 
of ulcerated gummata. The bones and joints often show lesions 
which represent other affections and yet yield only to antisyphilitic 
treatment. 

The nervous system is the part of the body which is quite fre- 
quently preferred by this abominable disease. The brain is often 
affected, many children die with meningitis, and the cause cannot be 
easily found unless the syphilitic taint is traced from their parents. 
Infantile paralysis is often found in children with a hereditary syphil- 
itic taint, and chorea nutans is by Comby considered as a nervous 
disease from syphilitic heredity. This sad heritage is the cause of 
idiocy, of epilepsy, of impaired intellectual development, of sexual 
perversion, of criminality, etc., which we will study in separate 
chapters. 

Ricord has asserted that nobody receives syphilis from his grand- 
father, and this assertion was accepted as a law for the very reason 
that in the third generation, clear infectious symptoms are not present. 
The question, however, began to be studied in a more general way, 
by ascertaining the presence of other possible alterations, which, if 
not directly of a syphilitic nature are yet induced in the system by 
the action of the syphilitic virus. In these cases syphilis has so affected 
the vascular system and has so influenced the general nutrition of the 
organism, as to render it liable to the attacks of other infectious 
elements and make it a good culture medium for their development. 

These manifestations have nothing characteristic of the syphilitic 
type, but have nevertheless some peculiar aspect, and are accompanied 
by some peculiar abnormalities, that an eye used to seeing syphilitic 
patients easily suspects to be originated from a syphilitic taint. These 
affections have been called parasyphilitic manifestations; they are 
not directly influenced by antisyphilitic treatment, because they are 
only different affections which find a good ground in a syphilitic 
organism. 

In this regard Jullien mentions the general debility of the infants, 
which is only the result of hereditary syphilis in the third generation. 
In his statistical notes it appears that twenty-nine infants from syphi- 
litic parentage have died from a few minutes after birth to a few 
months. In our service in the City Hospital we have had a large 
number of babies taken into the institution in an extreme degree of 
emaciation, who have died of marasmus in the first months of life. 
Unfortunately, these poor creatures are taken to the Hospital by others 
than their parents, and we can scarcely learn their names, let alone 



3IO THE MEDICAL ASPECTS 

obtaining any idea of their history. In these cases we believe it is 
more the effect of syphilis in the second generation than in the third. 

Returning to the cases of Jullien, he refers to an infant who 
suddenly died without any definite symptoms, and which Fournier 
said died without malady, showing the liability of these infants to 
do so. 

This vulnerability of their system is also manifested by the affec- 
tions which they often show, as obstinate cases of impetigo, otitis 
media purulenta, adenopathies, caries of the bones, and frequently 
their life ends with tuberculosis, which finds a good ground for its 
development. 

It will not be out of place to mention children affected with 
rachitismus. Every physician is certainly acquainted with the studies 
of Parrot, who thought he was able to refer the rachitismus to symp- 
toms of inherited lues. He was perfectly right in his views, but the 
acceptance of rachitismus as a symptom of hereditary syphilis was 
strenuously opposed. His opinion and his studies were taken up again 
by many syphilographers, and to-day Moncorvo, Callari, Moreira, 
Gibert and Jullien are inclined to consider rachitismus as a disease 
found in individuals of syphilitic parentage. In families where some 
of the children are affected with rachitismus, we find that frequent 
abortions have taken place. Rachitis is frequently associated with 
chronic coryza, with malformed and early decaying teeth, all pointing 
to the specific heredity of the sufferers. 

Many affections have been found in heredo-syphilitic children, 
which, however, have nothing in common with syphilis. It seems that 
the syphilitic taint has a tendency to favor the development of diseases 
of the respiratory organs, beginning with the nose in. the form of a 
chronic inflammatory process of the mucous membrane, and of adenoid 
vegetations in the posterior naso-pharyngeal cavity, and ending in the 
broncho-pulmonary apparatus as chronic bronchitis, leading to the 
development of tuberculosis. 

Monstrosities. — Syphilis as a hereditary taint from the parents at 
times displays a teratogenic influence on the descendants, with re- 
sulting monstrosities. Gley and Charrin have shown in their inter- 
esting works the production of monstrosities to be in a great many 
instances the result of syphilis hereditaria. In our practice we have 
observed two cases of acephalia, which occurred in two Italian families, 
in which both parents were syphilitic. Of the two monsters one was 
born already dead, and the second was born alive but died a few 
hours after its birth. They were well developed and well nourished, 
without a sign of syphilitic affection. 

Jullien refers to several observations, one from Le Pileur, of a 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 311 

case of hemophilia in a little girl, four cases of nevi communicated 
by Troisfontaines, Caubet, Torok; one case of malformation of the 
iris reported by Fournier, one case from Hamonic of cryptorchidismus 
and polydactylism, two cases of hare-lips, one case of monstrosity and 
one of a congenital amputation. 

When we recall the important alterations of the blood and lym- 
phatic vessels caused by syphilis, we will see that these affections 
peculiar to the vascular system as the hemophilia and the naevi are 
quite frequently the result of hereditary lues in the third generation. 

In the case of the hare-lip, which was communicated by Hamonic, 
it w r as found in a child well developed and apparently in good health. 
His father had a hare-lip, with a cleft palate, and he was the son of a 
syphilitic, who had a perforation of the palate from an ulcerated 
gumma. 

Dystrophia;. — The children born of syphilitic parents often show 
some abnormal development of their body. In some cases they are 
small, thin, and of a meager appearance, with a small waist, in other 
cases they are not proportionately developed. Moreira referred to a 
boy four years old only 55 centimeters high, and to a girl of eight 
years, who measured 92 centimeters. Lannelongue referred to a child 
born of syphilitic parentage, who showed abnormal disproportion be- 
tween the right and the left side. Barthelemy found a marked dis- 
proportion between the length of the femurs and that of the body, 
while Moncorvo pointed out an enormous length of both legs. We 
had already had occasion to report a case of a babe, the fifth offspring 
of a syphilitic father, born with only three fingers of the right hand, 
and a short humerus of the left side, ankylosed at right angles with the 
bones of the forearm, as is shown in the illustration. 103 In a general 
way we can see that the development of the heredo-syphilitic children 
is not regular, it is usually slow and somewhat tardy. It is often found 
that in those children, the appearance of the teeth is greatly retarded, 
so that in the second year of life they still have no teeth. Sometimes 
one of these children at the age of three years cannot speak, some 
cannot walk, a girl at the age of fourteen years does not show any 
development of the breast, has no menstruation, and all her acts and 
words tend to infantility. 

Often the skull shows some peculiar malformations, disproportions 
and deformities, which give an idea of the specific heredity. In some 
cases the fontanellse are ossified too early, in other cases they remain 
opened for a much longer time. In some cases there is microcephaly, 
in others macrocephaly ; in one the frontal eminences are greatly exag- 

103 Ravogli. " Considerations on Inherited Syphilis, with special reference 
to paternal inheritance." Lancet-Clinic. 



312 THE MEDICAL ASPECTS 

gerated, in another the parietal eminences are too pronounced. In 
consequence, there is a lack of harmony in the proportions of the skull 
which is revealed by the irregularity and asymmetry of the features 
of the face. The nose is often sunken in the middle ; the teeth often 
missing, deformed, badly disposed; all gives a peculiar specific appear- 
ance entirely characteristic of these beings. 

If such is the result of the syphilitic taint on the external appear- 
ance of the heredo-syphilitic individual, not less must be the deleterious 
influence on the development of the nervous system and of their mental 
faculties. In fact, we find these children rather tardy in learning; 
they are unable to study and they follow a conversation with difficulty. 
They are half idiots, sometimes with permanent defects of speech. 
Others are of rather an irritable nature, easily excitable, impulsive, 
passionate, some are inclined to erotic ideas, some are perverted. 

The teeth, as already said, are retarded in their growth, irregular 
in their implantation. They are small and separated, notchy, round, 
they show erosions, are easily broken, and subject to decay. 

The eyes are liable to show anomalies in heredo-syphilitic subjects, 
in the form of flecks, irregular or asymmetric pigmentation of the iris, 
pigmentary retinitis, strabismus, congenital or precocious cataract, the 
etiology of which has been attributed to syphilitic heredity. 

Deaf-mutism is in a great many instances due to congenital, rather 
than to acquired conditions. It is the result of osteitis or periostitis 
of the temporal bone, which affects the cavity of the middle ear, 
causing anchylosis of the ossicles, but more frequently of absence of 
the internal ear or any of its parts. It is also produced by colloid 
degeneration of the labyrinth, with atrophy of the auditory nerve, or 
from some lesion of the brain. Every one of these conditions finds 
syphilitic heredity as its principal cause. 

The skin of these individuals may also impress a diligent observer 
with its yellow parchment-like aspect ; in some cases the hair is scanty 
and limited in length, dry, easily falling out. Cyanosis has been found 
in one case by Moncorvo, and in another by Barthelemy. In in- 
dividuals descending from syphilitic parentage in the third generation, 
syphilis is not more transmitted as such, but only as alterations result- 
ing from its deleterious influence on the vascular system. It is there- 
fore revealed in the form of anomalies, arrest of development of organs 
or systems and for which the syphilitic process alone is responsible. 

Treatment. — In our experience with individuals affected with 
syphilis have undergone a long and regular treatment, and when the 
wife has remained exempt from infection, the children are usually 
spared. But when insufficient treatment has been used, and especially 
when the wife has been infected, the children are then sure to be in- 



TRANSMISSION OF SYPHILIS TO THE OFFSPRING 



3 J 3 



fected. If the infection has not been so virulent as to kill them in 
utero 3 they will show symptoms of congenital lues. They need treat- 
ment, which must be long and continued in order to save their lives. 
Some will get well after persistent and relapsing symptoms. The 
germs of syphilis when transmitted by heredity seem to be more 
tenacious and to have a better grasp on these poor creatures than they 
show in the cases of acquired lues. 

Hereditary syphilis is anomalous in its manifestations, so that a 
child born with multiple syphilitic dactylitis, after a few months has 
been known to show an eruption of ulcerated patches on the scrotum, 
while in acquired syphilis the evolution of the disease maintains a cer- 
tain rule in the progress of the symptoms. And thus was originated 
the distinction between the secondary and tertiary periods, which is still 
useful and of practical interest. 

The treatment of the individuals acquiring syphilis, or as we have 
called them, those of the first generation, is the only hope of safety, 
and the treatment must be a long continued one and repeated at in- 
tervals. When the parents of the first generation have neglected treat- 
ment and the syphilitic virus has been allowed to develop and saturate 
their organisms, then the influence on the family will be disastrous, and 
it will visit the third generation. Cases of so-called mild or latent 
syphilis are more dangerous for the reason that the patient thinks he 
is well, and is unwilling to undergo further treatment, and the physi- 
cian, deceived by the lack of symptoms, has not the determination to 
insist on the continuance of a treatment which seems apparently 
unnecessary. 

In the generality of cases, when a regular treatment has been em- 
ployed and the offspring has escaped the danger of death in utero, if 
it shows symptoms of lues it must be treated as we have above ex- 
plained. Under a regular treatment syphilis is attenuated and in the 
majority of cases it does not show further manifestations. In some 
families where both syphilitic parents had been under our treatment, 
we have found that the children, although not the picture of health, 
are bright and intelligent. The syphilitic virus with time and treat- 
ment keeps growing weaker, and is no longer transmitted to the 
children of the third generation as syphilis with virulent syphilitic 
manifestations, but it does exercise a deleterious action in the develop- 
ment of the fetus, inducing malformations or dystrophies, which at 
times are single and at times are associated. In many cases, malforma- 
tions do not occur in a visible way, but vices of conformation may 
affect the internal organs and especially the nervous system. 

The health of one of the parties contracting marriage has a great 
correcting influence on the health of the offspring. The symptoms 



314 THE MEDICAL ASPECTS 

found in the descendants are sometimes shown in an unequal and 
saltatory manner. For instance, a man who has suffered with syphilis 
marries a healthy woman, but is still taking treatment out of precau- 
tion. His wife will give birth to a healthy child, who during life will 
never show signs of hereditary lues. While ceasing from treatment a 
second child is born, and although apparently healthy, at some period 
of life will show some of the characteristic signs of retarded syphilis. 

We have so far no explanation for this saltatory transmission of 
syphilis by heredity and much less for that which concerns lues of the 
third generation. 

The explanation given by Jullien, 104 based on the alterations of the 
vitality of the cells caused by the toxins, may give an idea of the 
permanent or of the transitory character of the resulting lesion. The 
syphilitic virus is rather diffusible, but it is of a durable nature. It 
lasts and persists for years concealed in the latebrae of the organism. 
It is susceptible of attenuation from the biological changes produced 
by the metabolism of the cells, and it may also be eliminated spon- 
taneously through the natural cytophagic activity of the cells, and so 
taken to the natural excretory organs, from where it is eliminated. 

In many patients the elimination of the syphilitic virus is com- 
plete and recovery takes place, which has been proved by a large 
number of reinfections. This class of individuals can be considered 
as a favored one by so resistant a constitution that their tissues and 
cells will not retain the deleterious germs. They will have children, 
who will show no signs of the sad inheritance. On the other hand, 
there is another class of patients of a weak and unresistant constitu- 
tion, whose cells and tissues remain so persistently imbibed with 
syphilitic virus, that it seems nearly impossible to rid them of its 
pernicious influence. In this class of patients, if their system is not 
corrected, and its toxic condition not neutralized, it is an impossibility 
for their descendants to be free from syphilitic taint. This virus, only 
recently known in its entity, known better by its effects, affects blood 
and lymph vessels, and is carried to the remotest and most deep-seated 
cells of every organ and apparatus. If it is not transmitted as such it 
is yet capable at the moment of the formative stress to produce arrest 
of these organs so that imperfect development and anomalies of dif- 
ferent degree may result in the final product. 

104 Jullien, L. " Descendance des heredo-syphilitiques." Paris, 1900. 



PART II 

THE MEDICO-LEGAL AND SOCIOLOG- 
ICAL ASPECTS 



SYPHILIS AND MARRIAGE 

After all that we have considered in reference to the deleterious 
action of syphilis in families, we have reached a point at which we may 
propose to society some means to prevent young men infected with 
syphilis from contracting marriage after a short time and an insuffi- 
cient treatment. We do not consider syphilis as an absolute permanent 
obstacle to marriage, but it is only a temporary impediment, which is 
removed by a good and well-directed treatment. Only the physician 
who has pursued special studies in syphilology is able to decide the 
question of the admissibility of marriage for a man who has suffered 
with lues. 

SYPHILIS AN IMPEDIMENT TO MARRIAGE 

Every measure, as Burr x said, which is wise in its provisions, 
should have the hearty support of the medical profession. It is only 
through our profession that a knowledge of the extent and ravages of 
these diseases can be imparted, and means for their prevention pointed 
out. We can imagine but one prophylactic measure which is capable 
of preventing injury and death to innocent wives and children, and 
this is stringent laws regulating matrimony. 

Not all the applicants for marriage have received a good education 
and are capable of understanding the seriousness of their step when 
contracting' marriage still under the influence of the luetic infection. 
Nor are all applicants aware of the gravity of the disease and of the 
danger that their wife and family may take the disease, and conse- 
quently they fail to consult a physician in this regard. On the other 
hand, an innocent girl entering the bonds of marriage has a right to 
know that her own body shall not be contaminated through this rela- 
tion by an existing contagious disease or by a taint. The parents or 
relatives have a right to know that their offspring shall not be victims 
of hereditary afflictions. Every child has the inalienable right to be 
born well and not tainted with disease which later on will make him 
unhappy. 

The state alone can safeguard these rights by means of wise and 

stringent legislation. The same views were maintained by the mem- 

1 Burr, A. H. " State Regulation of Marriage for the Prevention of Com- 
municable and Hereditary Disease." Journ. A. M. A., Dec. 3, 1898. 

317 



318 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

bers of the Second International Conference of Brussels, which in the 
eleventh project of law, pointed out to governments and to the 
public the practical utility of a compulsory medical examination before 
marriage, in the form of an examination for life insurance. With 
these laws the state is able to prevent the diseased from contaminating 
the healthy and innocent through the license to marry. 

These rules ought to subject at least the groom to a sanitary 
visit before obtaining the license for marriage. In our country it is 
easily feasible on account of the necessity of the license from the 
Probate Court for the celebration of the ceremony. The license would 
no longer be a mere formality, but would be obtained when the indi- 
vidual is found in a condition to support a wife and family, and free 
from any disease which might infect his wife and make his family 
a burden to society. The examination for venereal diseases would 
have for its principal scope the protection of an innocent girl from 
undergoing all the tortures we have enumerated. 

Indeed, as taught by Ricord, stated by Noeggerath, repeated by 
all syphilologists and venerologists, the majority of males contract 
gonorrheal infection before matrimony. In a great many cases it 
remains latent for indefinite periods and is easily communicated to the 
wife, exposing her to all pelvic diseases. It is often a cause of sterility, 
and in the children is often the cause of blindness. In reference to 
syphilis, we have already pointed it out to be the principal cause of 
abortion and of stillborn children, and that tainted children usually die 
in the first year of life, enfeebled and lowered in their vital resistance. 
They are subject to many forms of nervous diseases, as idiocy, epilepsy, 
and also to some forms of insanity. At the same time, if the intended 
groom should be found to be suffering with pulmonary tuberculosis, 
it should be the duty of the physician to stop and impede so unfortunate 
a match. Consumption is the great white plague, which cuts down 
from one-ninth to one-seventh of the human race, and it is often com- 
municated through marriage, and the children are born with a weak 
constitution and have a tendency to tubercular affections. 

We have already seen that syphilis has a tendency to increase 
mental and nervous derangements, and the tainted person by marrying 
is liable to beget offspring belonging to the class of physical and 
moral degenerates. This class of people give the largest contingent 
for the diseased, for the defectives, and for the criminals, which largely 
fill asylums, poorhouses and jails, and remain for the state to care for. 
For this reason the state has a right not only to protect the individual, 
but also to protect society, by diminishing the number of those who 
might remain as a burden to the public welfare. 

In this way the appointment of a physician by the Probate Court 



SYPHILIS AND MARRIAGE 319 

for the examination of the man applying for the marriage license 
would be the most desirable solution of this sociological problem. 

French authorities have proposed that the candidate for marriage 
should exhibit a certificate from a physician, which would be the 
sanction or the prohibition of his marriage. This procedure is greatly 
praised by Jullien, who finds that the father of the bride would be 
relieved of much anxiety in reference to the health of his intended 
son-in-law. 

We find a serious objection to this manner of certificate, for the 
reason that it will give opportunity for a great many mystifications, 
which can easily be avoided, when the physician is appointed by the 
Court and is selected from among the most reputed specialists in this 
line of science. 

We do not agree with the opinion of Morrow, who alleges great 
hostility of public sentiment in this country against such a restrictive 
measure. Here is the necessity of obtaining a license, and in order 
to obtain this valuable document an examination has to be made to 
determine the fitness of the applicant. 

In so grave a question, where the happiness of a family is at 
stake, theories and poetry count for nothing. The visit has to be 
made in order to ascertain whether Mr. X., who applies for a marriage 
license, actually has syphilis or a gonorrheal infection, which will 
without doubt infect his wife. When no symptoms are present, when 
the man, if he has been infected, has undergone a regular treatment 
for the period of three to four years, when no gonococci are present 
in the gleety discharge from an old stricture, nobody will refuse to 
this man the requested license. 

At this moment in several States in the Union a movement in this 
direction is gaining ground, and before long it will be a law. In this 
case the license will be a clean patent that the man contracting mar- 
riage is not in a condition to infect his wife with venereal diseases. 
The idea that such a law will promote celibacy, as Morrow states, 
because self-respecting persons would rather forego marriage than 
be subjected to such a humiliating condition, is nothing more than a 
bugaboo. No self-respecting person foregoes life insurance because of 
the sanitary examination. Very likely a man infected with syphilis 
will refuse to show his condition to the examining physician, and 
will become so self-respecting as to forego marriage on account of 
evading a sanitary visit, which would place him in a humiliating 
position. 

The other objection, that many aspiring to marriage will go to 
another State where such a law is not in force, may be true, but we 
do not care. Anyone who has done anything wrong and wants 



320 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECT 



to evade the law may do so if he chooses ; he will suffer the conse- 
quences. 

Jullien related that the Minister of Justice of Spain was so greatly 
wrought up over the sanitary conditions, especially relating to venereal 
diseases, that he wished to have a physician intervene in every request 
of inscription for marriage. In our short stay in Spain we have seen 
in the streets of several cities children affected with grave manifesta- 
tions of inherited syphilis carried around by sickly mothers to arouse 
sympathy among the passers-by and obtain alms. 

The Probate Court ought to require from every applicant for a 
marriage license the production of a certificate from a doctor specially 
appointed by the same court, stating that the applicant is free from 
contagious diseases. This certificate will make the license a document 
of great value and not a simple formality ; it will prove a blessing to 
a great many families and to future generations. 

The physician should be a man thoroughly familiar with derma- 
tology and syphilology, and should consider the matter only from the 
actual sanitary standpoint. The visit for a life insurance is a different 
question from that for a marriage license. The insurance companies 
are interested in the future consequences of syphilis in reference to 
the longevity of the applicant, in the visit for a marriage license the 
question rests on the inoculability and transmissibility of the disease. 
The physician therefore has to consider the proposed marriage only 
as a sanitary problem. The solution of this problem is that a man 
must not be permitted to marry as long as he is in a condition to 
infect his wife, or to transmit syphilis to his children. We hope that 
in the near future a case of syphilis will find in the microscopical 
examination, data which can be of valuable help in the determination 
of this question ; so far at present the judgment of the physician must 
rest in the knowledge of the alterations of the disease, and on the 
clinical observations. The point is that there are no signs of syphilitic 
manifestations, which are of an infectious nature, and that the appli- 
cant for the marriage license has no signs of recently acquired syphilis. 
Moreover, if the applicant should still have signs of an old, extinct 
lues, or he should admit having had lues, it would be the duty of this 
examining physician to determine the time elapsed from the first in- 
oculation and the quality of treatment undergone. Indeed, it is 
impossible to establish with certainty the time when a man who has 
been infected with syphilis will be out of quarantine and will not be 
dangerous for spreading infection. We have already seen that the 
disease may have different degrees of gravity on account of the quan- 
tity of virus, of the association of other infectious germs, and also on 
account of the constitution and of the healthy condition of the general 



SYPHILIS AND MARRIAGE 321 

svstem of the patients. The method of treatment which has been 
employed, the time for which it has been continued, the easy yielding 
of the syphilitic manifestations, are all data which should exert a great 
influence in the consent for a license for marriage. 

When the infection dates from several years, and for years no 
manifestations have appeared again, when the patient has taken a 
regular treatment continued for a number of vears and no more 
symptoms have shown, he can be safely considered out of any danger 
of transmission of the disease. 

The assertion that after three or four years, and worse still that 
after two years syphilis is extinct and the syphilitic man can safely 
marry without fear of inoculation or of the transmission of lues to the 
offspring, is absolutely erroneous. It is possible that in a certain 
number of cases after the second or the third year no more symptoms 
appear and the disease loses its contagiosity and its transmissibility ; 
but we also see cases where after the fifth, the sixth, and even the 
eighth year, mucous patches still return and the disease is still capable 
of being inoculated. 

We have already seen that the transmissibility of lues from the 
father to the offspring persists longer, and that although all symptoms 
have practically disappeared, yet the children may become tainted with 
inherited lues. In general we can assert that when a man infected 
with syphilis has undergone a regular treatment, for a period of four 
years, and for over a year no specific symptoms have reappeared, he 
can be released from quarantine and can safely be permitted to marry. 

With a well-regulated office of this kind for the sanitary inspection 
of the aspirants to marriage, there would be obtained a prevention of 
the spreading of syphilis and its introduction into the families with the 
sad and fatal consequences which we have already considered. The 
objection that the couple will elope and have their marriage celebrated 
in another State does not diminish the good and the benefit of the 
institution of such an office of public hygiene. The possible benefit 
will be appreciated by the different States and very likely the law will 
be adopted by many, so many that it would not be easy to find a place 
to avoid the law. Furthermore, we are trying to diminish the evil by 
preventing the introduction of infectious diseases into the family, and 
if they do not understand the importance of the health of the family, 
the responsibility rests entirely with them. 

SYPHILIS AS A CAUSE FOR DIVORCE 

Syphilis, or better, venereal diseases, have not had a very extensive 
consideration in courts of justice. The only recognition for judicial 
determination has come in cases for divorce, and as these are usually 



322 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

final in the lower trial courts, few cases reach the highest tribunals 
where the laws are established and become precedents in the archives 
of the legal profession. In but one State of the Union is there a direct 
law touching the subject in question. 

Judge Otto Pfleger kindly stated to us that the Kentucky legisla- 
ture in 1897 passed a law granting a wife a divorce on the ground that 
the husband had contracted a loathsome disease, and in one adjudicated 
case (41 Southwestern Reporter, p. 26) gonorrhea has been classified 
as such a disease. 

Almost every State has " cruelty," or " extreme cruelty " as a 
ground for divorce. This is not confined to personal violence. The 
weight of English, Scotch and American authorities is to the effect 
that any misconduct which tends to impair the health or which creates 
an apprehension of bodily injury is cruelty (see Vol. 9, " English and 
American Encyclopedia of Law," p. 788.) 

Therefore to willfully communicate a venereal disease is clearly 
cruelty, for it is misconduct tending to impair the health and to render 
cohabitation unsafe. This has been so held in the Supreme Courts of 
England, Connecticut, Maine, Michigan, New Jersey, North Carolina 
and Tennessee ("American and English Encyclopedia of Law," Vol. 
ix, p. 792.) 

This ground is not, however, available to the wife if she continued 
to cohabit with the husband after knowledge of such a disease, unless 
she was unaware of the dangerous nature of it. It must, of course, 
be made clear that the wife contracted the disease from the husband. 
In a late case in California (94 California Reports p. 225) it was 
determined that communicating gonorrhea to the wife is cruelty as 
defined under the statute. 

In the law books we find great lack of knowledge in reference 
to syphilis. All that is spoken of is venereal disease ; gonorrhea and 
syphilis being confused as one. 

Under the head of adultery as a ground of divorce we find some 
adjudications regarding venereal diseases. In the American courts 
not much is thought of their presence, because of the uncertainty of 
establishing adultery. 

In New York and Massachusetts adultery may be inferred, where 
the husband had contracted a venereal disease long after marriage, 
although it was said that such a fact is not always incompatible with 
innocence. Adultery, therefore, will not be inferred from the presence 
of the disease shortly after marriage, as it may have been contracted 
before marriage, or be due to a return of symptoms of secondary 
syphilis. 

Proof that the wife had syphilis will not bear the inference that 



SYPHILIS AND MARRIAGE 323 

the husband committed adultery inasmuch as she may have contracted 
the disease by her own adultery, by contagion or by accidental means. 

All of this goes to prove that the courts have found difficulty in 
fixing the blame on the guilty party by the mere presence of venereal 
troubles. 

Bishop 2 too, considers one of the principal causes proper for 
divorce, extreme cruelty, which renders cohabitation physically unsafe. 
For a husband knowingly to communicate venereal disease to his wife 
is adequate legal cruelty and in aid of the necessary proofs of knowl- 
edge, the presumption will be that he was aware of his own diseased 
condition and of the danger of infection. But it has been deemed that 
for a man to marry while this disease is on him, and thereby endanger 
his wife, is not legal cruelty, if in fact it is not taken by her. But in 
reason, this favorable construction of the act would arise simply from 
the presumption that he had used precautions to prevent infection. 

A husband's attempt, while he has venereal disease, to force his 
wife to his bed, is regarded as of a mixed nature, partly cruelty and 
partly evidence of adultery. 

Venereal disease is presumed to come from sexual commerce and 
prima facie proof of a husband's adultery has been deduced from his 
having it long after the marriage. Its appearance soon after mar- 
riage, as above stated, does not lead to this conclusion, because ante- 
nuptial misconduct may have produced it. But even in the former 
case, if we look rather to the legal reason than to specific authority, 
we shall find it necessary for some evidence to appear that he was 
not infected by the wife, for in so intimate a relation, where the disease 
of one party must almost of necessity extend to the other, how can the 
court in the absence of proof charge the guilt specifically upon either? 
Looking again to adjudication, where there was an attempt to establish 
adultery against the husband by showing the wife to be suffering 
from recent infection, Dr. Lushington 3 considered this fact not alone 
sufficient, since she might have contracted the disease from another. 
He claims that it is impossible to lay down any general inflexible rule, 
for each case must depend upon its own circumstances, and these 
must assist the court in coming to a conclusion. 

By a judicial committee the doctrine was stated to be that the 
adultery of the husband cannot be inferred from the mere fact of the 
wife's being tainted with venereal disease, although she herself is not 
even suspected of adultery ; that its existence in her is consistent with 
the adultery of the husband, with her own adultery, and with accidental 

2 Bishop, J. P. " Commentaries 011 the Law of Marriage and Divorce," 1881. 
vol. i, p. 736. 

3 Lushington, quoted by Bishop, 1. c, vol. ii, p. 633. 



324 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

communication of it, and that where there is no proof of the husband 
having been himself diseased at the time specified in the libel, it will 
not be ascribed by preference to the first of these causes, even though 
it appears that at a former time he had infected his wife. 

In principle, if we reject the somewhat prevalent idea that acci- 
dent may bring this disease where the usual cause does not, and if 
in a particular case it is found to have originated long after the mar- 
riage, then the conclusion is plain, that one or the other of the parties, 
or both, must haye offended. Now how shall we determine at whose 
door the guilt lies? Often we cannot; but in a case of this kind, con- 
sulting reason rather than specific authority, evidence should be re- 
ceived of the entire course of life, and the associations and temptations 
of the parties respectively, the result of which would be, that some- 
times the judge might become fully satisfied and sometimes not. and 
the divorce would be granted only when he was satisfied. 

DAMAGES IN CASES OF SYPHILIS 

The question of damages in case of syphilis alleged as an impedi- 
ment to marriage has been fully ventilated, and we can state that this 
matter has been nearly settled by the courts. In some cases syphilis 
could have been alleged as a pretext to break a contract of marriage, 
although the condition of one of the parties would have been not such 
as to require the nullification of the contract. And by this means the 
responsibility of damages or of an indemnity which is asked in cases 
of breach of promise would be escaped. 

It is better for us to look into some practical cases in the judicial 
courts, in reference to syphilis as an impediment to marriage and as 
a cause of divorce. From these cases we will learn a great deal about 
what the jurists think in this matter. For this reason we will refer 
to the case of Shackleford vs. Hamilton, which has gained so much 
notoriety, and the decision rendered by Judge Prior in this case has 
been adopted by all the jurists. 4 

It is implied as a part of every agreement to marry, that any 
subsequent change in the mental or physical condition of either party 
without fault, so as to render it impossible in the nature of things to 
accomplish the objects of the marriage relation, will release the parties 
from the agreement. 

Where a man who had contracted syphilis entered into an agree- 
ment to marry, believing in good faith that he had been cured of the 
disease, the reappearance of the disease without fault on his part, so 
as to render him unfit to marry, released him from his obligation, and 

4 " Reports of Civil and Criminal Cases Decided by the Court of Appeals of 
Kentucky," vol. xi, Frankfort, Ky. 1894, p. 80. 



SYPHILIS AND MARRIAGE 325 

constitutes a good defense to an action against him to recover damages 
for breach of the contract. 

The attorney for the appellant produced the following legal points : 

I. Matrimonial intercourse is the principal end of marriage, and 
where by reason of supervening disease or impotency this end cannot 
be answered, either party to a contract of marriage may refuse per- 
formance without incurring any liability ; provided, the changed con- 
dition was not brought about by his fault. 5 

We shall not enter into the legal technicalities of the case in 
reference to the tenability of the contract, and to the circumstances 
which justify a verdict for exemplary damages, but we will dwell 
strictly on our subject, syphilis as a ground for the release of a party 
from the contract of marriage. 

Indeed, there is no implied term or proviso in an ordinary contract 
to marry that syphilis, whether contracted before or after the en- 
gagement, should release the syphilitic party from performing his 
contract or paying damages for its breach. In the case in question 
the defendant admitted that he made the contract of marriage when 
he believed himself to be in good and sound health. Before any con- 
tract of marriage he had contracted syphilis, for which he was treated, 
and after steady and good treatment he had been pronounced cured 
and free from the malady. He stated that he had consulted another 
physician, who after a thorough examination of his person, assured 
him that there was not the slightest evidence of the existence of the 
disease, and his regular physician who had treated him during the 
time of the disease had told him that he was cured and in a fit state 
to marry, which he could safely do. 

After this time, with the belief that the disease no longer existed, 
he made the contract of marriage. He stated that after the engage- 
ment to marry and without fault on his part, symptoms of the disease 
again appeared, and so he was advised by his physician not to marry. 

In the case, the judge took under consideration the possibility that 
the reply could have been prompted by the view of escaping the re- 
sponsibility in the way of damages, rather than by an honest conviction 
of his physical condition. The judge, however, based his judgment 
on the testimony of the physician, who gave satisfactory evidence on 
the alleged facts. 

The court below had sustained that as the man had entered into 
a contract of marriage, he was bound for its breach, that the contract 
was unconditional and the man being able at the time the promise was 
made to perform the contract, he must either execute it or become 

5 Quoted from Bishop " On Marriage and Divorce," vol. i. Sees. 321, 322. 
P- 657^ 



326 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

responsible in damages for the breach. The judge in this case remarked 
that a contract of marriage is not a mere bargain, to be viewed as an 
exchange of chattels between the parties competent to contract. But 
marriage is an agreement to create a status that forms the basis of 
our social system, and in which society has more interest in preserving 
its purity than the parties concerned. 

When the marriage contract is consummated, the parties taking 
each other for better, for worse, for richer, for poorer, and agreeing 
to cherish each other in sickness and in health ; the fact of the social 
standing of the one party or the other, or their pecuniary condition 
was not as represented, will afford no ground for relief. Still, when 
there is only a mere agreement to marry, there may be such a condi- 
tion of the one party or the other as to health or other bodily infirmity 
arising subsequent to the agreement, as would authorize either party 
in declining to enter into the marriage relation. Bishop 6 maintains 
that, " after marriage one cannot complain of an impediment known 
to him before ; but if he were ignorant of the existence of the defect, 
or of its incurable nature, though in himself, he may take advantage 
of it by suit of nullity. The marriage was a mistake ; the ends intended 
by it cannot be answered." 

Without sexual intercourse the ends of marriage, the procreation 
of children and the pleasures and enjoyments of matrimony, cannot be 
attained. According to Ayliffe, the first cause and reason of matri- 
mony ought to be the design of having offspring, the second the 
avoiding of fornication. The law recognizes these two as its principal 
ends. If the disease is merely temporary and the change in the 
physical condition of a party to a marriage contract, without his fault, 
is such as to render him less capable to discharge duties in the marital 
relations, it would be sufficient to justify its breach. But when the 
party is afflicted with a disease which is dangerous to the health of 
the party who comes in contact with him, as it would be necessarily 
communicated by sexual intercourse, and through her to affect their 
offspring with the poison, when it is connected with the fact that he was 
ignorant of the disease being upon him at the time he contracts to 
marry, he will be excused for the non-performance of his undertaking. 

While the contract to marry is silent as to any condition, it must 
be implied that any subsequent change in the physical or mental con- 
dition of either party, without fault, so as to render it impossible in 
the nature of things to accomplish the objects of the marriage relation, 
will release the parties from agreement. Impotency, insanity, or such 
a diseased condition of the body as would affect the offspring and 
endanger the life of the mother if the contract were carried out, would 
certainly be within this rule. 

6 Bishop. " Marriage and Divorce," 6th Edition, p. 582. 



SYPHILIS AND MARRIAGE 



3 2 7 



Another case of the kind is reported as Allen vs. Baker, in which 
the opinion was delivered by Justice Ruffin. The defendant refused 
to comply with his contract because he was affected with syphilis. 
The disease was contracted before entering into the contract, but he 
had been advised, and firmly believed that he could be cured in time, 
and so be enabled to fulfill his engagement. The judge said that 
acting in good faith, and from a conscientious conviction that his 
disease was incurable, he refused to comply with his agreement. The 
court in that case said, 7 " We cannot understand how one can be 
liable for not fulfilling a contract when the very performance of it 
would in itself amount to a great crime, not only against the individual, 
but against society itself." In this case the judge found that if the 
defendant would be compelled to marry and avail himself of his con- 
jugal rights, he would necessarily communicate syphilis to his wife 
and to his offspring, and that to inflict upon him punishment by way 
of damages for not executing the contract, would be compelling him 
to do that which is against law, human and divine. 

The disease renders him incapable of marriage without actual 
damage to the life of the woman by communicating to her and through 
her to their offspring a disease which is now gradually destroying 
this man. No greater crime in law or morals could have been com- 
mitted than the performance of his agreement. The purity of our 
social system, the interest of the public in preserving sacred the marital 
relation, the protection of those whose existence may spring from such 
an unholy alliance, as well as the future welfare and happiness of the 
parties themselves, require that such a construction should be given 
to this class of contracts. He maintained that the answer of the de- 
fendant presented a valid defense and in consequence he reversed the 
judgment. In the Court of Common Pleas of Hamilton County, 
Ohio, Judge Frederick Spiegel decided a case of application for 
divorce of a man perfectly healthy, who had married a syphilitic 
woman. The reason for which divorce was asked was on account of 
infected children. The man, before marrying, knew that the woman 
had been syphilitic, but she assured him that she had been perfectly 
cured. After a few months of marriage the wife conceived, and at 
the end of the fifth month she had a miscarriage. After this she 
became pregnant again and a stillborn child was the result. The 
third babe was born alive, but two weeks after was covered with 
papular syphilide. Treatment was instituted and the babe grew better 
of the eruption, but after a while it began to suffer with eclampsia 
and was affected with hemiplegia. 

After such terrible consequences the husband began to brood 

* 86. N. C, 91. 



328 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

over his condition and look to his wife as the cause of his misfortune, 
and he applied for a divorce from her. The court appointed two ex- 
perts to investigate the condition of the health of both parties and 
report. We examined first the husband, a man thirty-two years old, 
a fine specimen of manhood ; he did not remember of ever having 
been sick in his life. The most careful examination failed to reveal 
any syphilitic sign. In consequence he was declared perfectly healthy. 

The examination of his wife was as follows : A small and sickly 
woman, anemic, exceedingly nervous, admitted to have been acci- 
dentally infected with syphilis for over nine years. In fact, on the 
internal surface of the mucous membrane of the inferior lip she showed 
a well-marked cicatrix where the initial lesion took place. The tongue 
and the mucous membrane of the cheeks still showed opaline patches, 
and the arch of the palate was red with dilated blood vessels. Cer- 
vical, subaxillary, epitrochlear and inguinal glands were still hard and 
perceptibly bore witness of the syphilitic adenopathy. On one of the 
shoulders a whitish scar, round in shape, showed that she had been 
affected with cutaneous gummata. 

The report was favorable to the husband. The judge, starting 
from the object of marriage, which is propagation and continuation 
of the species, found a healthy man bound to a sick woman. The 
result of such a marriage had been abortions, stillbirths, and one sick 
and paralyzed babe. This man with another woman could be happy 
and have a healthy family. The judge on this ground declared there 
was sufficient reason to dissolve the marital vows and have both free. 
He therefore granted divorce. However, as the husband had known 
that the woman he was going to marry had been syphilitic he accorded 
an alimony to the wife of $1700 and that the husband should pay the 
cost of the trial. 

This he cheerfully did so as to be free from a woman who on 
account of the syphilitic infection had become a disagreeable object 
to her husband. 

In our courts syphilis is considered a cause for divorce as a form 
of extreme cruelty. Indeed, a man who knows he has been infected, 
who has been warned by his physician not to marry on account of the 
danger of infecting his wife, commits, if he marries in spite of all, an 
act of extreme cruelty, and that woman who has been infected has a 
right to redress in the courts of justice. 

Honor must be attributed to the legislators of the State of Michi- 
gan, who in their session in 1899 enacted that: " Any person who has 
been afflicted with syphilis or gonorrhea, and has not been cured of 
the same, who shall marry, shall be deemed guilty of felony, and upon 
conviction thereof in any court of competent jurisdiction, shall be 



SYPHILIS AND MARRIAGE 329 

punished by a fine of not less than five hundred dollars, or more than 
one thousand dollars, or by imprisonment in the State's prison at 
Jackson not more than five years, or both such fine and imprisonment 
in the discretion of the court." 

The fact remains, as Valentine 8 says, that Michigan stands in the 
front of the world in recognizing the dangers of uncured syphilis and 
gonorrhea. 

Syphilis, as one of the most repulsive of diseases, which con- 
taminates the healthy wife, which infects the offspring, which brings 
death or disease to the children, offers a good ground among acts of 
extreme cruelty for obtaining a divorce. 



THE MEDICAL SECRET 

Before leaving this part concerning the individual infected with 
syphilis, we wish to examine briefly two important questions which 
have reference to the physician in his relation to his syphilitic patient. 
The first is whether the physician is bound to maintain the medical 
secret in reference to syphilis and to what extent. This interesting 
subject was masterfully treated by Morrow 9 at the meeting of the 
American Dermatological Association in Washington, under the title 
of " Syphilis and the Medical Secret." The physician, no matter what 
theories or what dogmas he may follow, no matter to what school or 
sect he may belong, finds himself always under the obligation of 
secrecy in reference to any information of a patient's condition which 
he has obtained in the exercise of the profession. This is the Hippo- 
cratic oath, accepted and respected by the best medical men of any 
time, and considered as the duty of the physician towards his patients. 
It has always formed the code of duty, and a just and discreet pro- 
fessional secrecy is the base on which rests the principle of the con- 
fidential relations between physician and patient. 

If the patient expects so much from his physician in general, he 
expects much more of him in reference to venereal diseases, which on 
account of their shameful character would injure him in his social 
standing. On this tacit contract the patient goes to the physician and 
confides to him his secret trouble, relying on his discretion that his 
secret will never be divulged. 

The State, however, under the consideration of the necessity of 
preventing the spreading of contagious diseases, has made the social 
welfare- much superior to the interests of the individual, and has com- 

8 Valentine, F. C. "The Irrigation Treatment of Gonorrhoea," p. 212. 

9 Morrow, Prince A. " Syphilis and the Medical Secret." The Journal of 
Cutaneous Diseases, June, 1903. 



330 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 



pelled by law the physicians to report all cases of contagious diseases 
dangerous to the public health. In this way the authorities, notified 
of the existence of a disease of a contagious character, are enabled to 
isolate the case and protect the public from its spreading. 

Although syphilis and the venereal affections are of a contagious 
nature, in most of the countries they have not yet been included among 
those to be reported. In Norway and in Denmark, however, the ven- 
ereal diseases must by law be reported by the physician just as any 
other contagious affection. With this measure they claim a great gain 
in the diminution of the venereal diseases, for the reason that the 
authorities are able to locate the dangerous sources of contagium and 
keep them under surveillance, and compel the infected individuals to 
undergo a thorough treatment. We, however, do not agree with their 
opinion, and we believe that the obligatory denunciation by the physi- 
cians of all venereal affections to be dangerous and injurious to the 
community. The reported diminution of venereal affections is rather 
ephemeral, and according to our opinion finds its cause in the conceal- 
ment of the venereal afflictions. When a man is infected, instead of 
going to consult a good physician or a specialist, he will avoid him as 
a spy, because he knows that he will report his case to the sanitary 
bureau. He will conceal his sufferings, and will rather consult a drug- 
gist or an herboiist, but will never go to a respectable physician. As 
a consequence, this measure will tend to increase the chances for quacks 
and charlatans, who, being unscrupulous, will avoid the law and extort 
money from the unfortunate victims. As long as the infected indi- 
vidual remains by himself and follows the rules given him by his 
physician, there is no trouble in maintaining his secret. But there 
are a great many circumstances where the health of others is con r 
cerned, and the physician finds himself in the dilemma of revealing, 
or at least of making known, his secret, or exposing the health and the 
welfare of others. 

In the case of marriage, for instance, it is the duty of the physi- 
cian to explain to his patient the danger of syphilitic infection for the 
wife, and of the hereditary transmission of syphilis to his children. 
The patient, therefore, has to subject himself to a long and thorough 
treatment for a period of years, before he can venture married life. 
Most of the patients readily accept the advice of the physician, and on 
their part there is no trouble. In some circumstances, however, it will 
happen that a patient, fully aware of the importance of the disease 
with the resulting dangers, will still insist on the necessity of his 
marriage. In some cases the marriage has already been announced, 
and it would be an impossibility to postpone or break off the engage- 
ment. In other cases, for other reasons he will insist on g-ettinq- mar- 



SYPHILIS AND MARRIAGE 



331 



ried, exposing in this way an innocent girl to the ravages of syphilis. 
In cases of this kind the idea of keeping the secret would be nothing 
else than abetting a crime, and we do not see any duty on the part of 
the physician of sticking to his obligation of secrecy. In this case it 
is the question of saving a young woman from the ravages of syphilis. 
Only the physician knows that the intended groom is infected and 
will surely infect her, and he is the only man who can save her from 
the sufferings and the torture of syphilis. 

The Hippocratic oath enjoins, 10 " My tongue shall be silent as to 
the secrets which are confided to me, and I will not use my profession 
to corrupt manners or aid crime." 

AVhen we are persuaded that the marriage of such a man is nothing 
more than a contemplated crime, which he wants to commit on account 
of selfishness and even of sordid motives, then it is our duty as men 
of honor to stop such an iniquitous wrong. This code cannot be made 
to protect a man who seeks to make unhappy an innocent woman in 
her married life, and in this case a hint given to her family physician 
would be a blessing for that family. 

We cannot refrain from reproducing the following case referred 
to by Langlebert, and quoted by Morrow : " The father of a young 
woman asks information relative to the health of a young man (your 
patient) w T ho is engaged to his daughter. ' I wish to ask under the 
seal of secrecy certain details as to his malady. I beg you to say 
whether I can or cannot accept him as a son-in-law. I hope that you 
will take into consideration the embarrassment of a father placed 
between the desire to give his daughter the husband of her choice, 
and the fear of the results the marriage may have if the hints that 
have been given me are unfortunately true.' " 

" In the case given above," says Langlebert, " should the physician, 
entrenching himself behind the Hippocratic oath and the prescriptions 
of the law, keep absolute silence, or only interrogating his conscience, 
should he make it the judge of the secret confided to him, to divulge 
it or be silent, according to the circumstances ? " 

We do not differ from the opinion of Dr. Goide, who in com- 
menting upon this case said : " If a client affected with constitutional 
syphilis, which resists all treatment, does not fear to solicit the hand 
of a pure young woman, who is the joy of her family ; if the father 
of this young woman comes to demand of me in confidence if he can 
in all security give her to this man who would soil her by his first 
contact and leave her as her only consolation children affected by his 
malady, shall we respond by a silence which may be misunderstood, 
and thus render ourselves accomplices of a marriage, the fruits of 
which will be so deplorable? Never would I have the courage to 

10 Morrow. L. c. 



332 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

obey the law under such circumstances. My conscience would speak 
higher than it and without hesitation I should say, ' No, do not give 
your daughter to this man,' and I would not add another word." 

Langlebert indicates the physician's role as follows: "I regret 
that I cannot give the information you ask. The least you can do, if 
you intend to carry out this project of marriage, is to inform the 
young man of the warnings you have received, or have him come with 
you or send me a note by which he authorizes me without restriction 
to say whether he can or cannot espouse your daughter. 

" The physician ought to interdict all kinds of information as to 
the health of a patient on the occasion of marriage ; as a professional 
principle, an invariable rule of conduct, he should take refuge behind 
the proscription of the law. 

" The alternative is cruel ; it requires a certain courage in such 
cases for the physician to remain master of himself and faithful to his 
duty. 

" If it be a misfortune to society, it would be a much greater 
damage to permit the enfeeblement of the tutelary principle of the 
medical secret, which is one of the necessities even of the social order." 

Much ado about nothing ! In our estimation this medical secret 
in the circumstances referred to is greatly overrated. We do not be- 
lieve that we serve as detectives, no, but when a father of an intended 
bride comes to us and asks if he can marry his daughter to Mr. X, 
our patient, and we know that he is affected with syphilis in full blast, 
we believe that it would be cruel not to reply frankly, " No," or at 
least, " Not at present." That no will save that poor woman from so 
many sufferings, will save her from having dead or sickly children, 
will save a family from many troubles. 

Indeed, we must approve the frank and decided way of Juhel 
Renoy, who claims it not only lawful, but compulsory, for a doctor to 
oppose and even denounce any criminal project which his patient may 
entertain in reference to marriage. So decisive an action is greatly 
disapproved by Jullien, who goes so far as to call the action of his 
colleague a treason, for the reason that his patient confided to him 
the secret of his disease, as a secret, fully persuaded that it would not 
be divulged. 

Of the same opinion is Thibierge, who is also firmly convinced 
of the necessity of maintaining the medical secret. He claims that 
although the physician is troubled in his conscience on keeping the 
secret, regarding himself almost as an accomplice in an action which 
he condemns, yet he must never forget that " no one is sufficiently 
sure of his conscience to put it above the law." He states that the 
enforcement of the obligation of the medical secret is an indispensable 
condition for the public prophylaxis. When the patient could not rely 



SYPHILIS AND MARRIAGE 333 

on the silence of his physician, he would rather go to a quack from 
whom he can buy secrecy. Timorous patients, under the wrong im- 
pression of having had syphilis when they had only a slight venereal 
accident, laboring under the idea that a syphilitic man must not marry, 
may remain celibates. Others who had a very mild case of syphilis, 
for the fear of confiding their secret to a physician, would remain 
without treatment and then marry and so infect their wives. While 
others, having had syphilis many years previously, under the impres- 
sion that it was not safe for them to marry, would remain single. He 
concludes that from the relaxation from the obligation of the medical 
secret there would result grave disadvantages for individuals and for 
society. 

We do not deny that in all his arguments there is some truth, we 
know well that the syphilitic patient wants to conceal his trouble, and 
is therefore constantly on his guard against anything which might 
raise suspicion as to his condition. We maintain the secret of our 
patients and we consider it as sacred as our word. In the ordinary 
cases, when our patient has been warned not to marry for two or 
three years, he accepts the word of the doctor as final and will not 
speak of marriage until he has his physician's assent. If a man 
infected with syphilis and warned of the danger of infecting his wife 
if he should marry, still persists in his intended marriage, he does not 
tell us who his intended bride is nor where she is. Neither has it 
ever happened to us that a patient has insistently replied, " I want to 
get married in spite of your warning " ; but they remain silent, or they 
say, " we'll see about putting it off," or " I will take my time." In 
this way the physician has no idea that his patient will get married 
in the condition in which he is, and although he should have the 
suspicion that his patient will carry out his purposes, yet it is im- 
possible for him to do anything to prevent the consummation of 
marriage. 

If as an exception there should present itself to us a repetition of 
the case of Langlebert, then without saying what is the disease for 
which the intended son-in-law is under our treatment, we should 
advise the gentleman to postpone the marriage of his daughter in- 
definitely, as his intended son-in-law is too sick to get married. 

We believe that a reply in this sense will not be against the 
obligation "of the medical secret, and at the same time will put on their 
guard the family of the intended bride and postpone the nuptials. 

If it should happen that a patient with a recent attack of syphilis 
were such a brute as to insist on his intended marriage with the 
certainty of infecting his wife, then we will say with Morrow, that 
the physician must be guided by his own conscience and light in the 



334 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

matter. In such a case a monster who has no feelings, no heart and 
no conscience would not deserve to be protected by the professional 
secret, and the physician who would remain indifferent to the perpe- 
tration of such a criminal act, disclaiming all responsibility on account 
of the law of medical secrecy, would deserve all the blame. 

We have had other cases where the medical secret could not be 
maintained. A young man after his graduation from a literary college, 
finding himself free from its yoke, trying to sip the pleasures of the 
world, contracted syphilis. A mild roseolar eruption followed and 
he came under our treatment. His father, who was already aware that 
his son was no more in good health, found some bottles with our name 
on them. He called, and with exquisite kindness requested to know 
the ailment of his son. In this case it was the father who wanted to 
know from what his son was suffering; it was not a case of making 
the secret known to anybody else for any purpose, but was for the 
protection of the family. The reply was that his son was affected with 
syphilis. It was a case where the question could not be answered in 
any other way. The secret remained buried in the family for the 
protection of the others. 

It has happened, although very rarely, that we have been called 
before the court to testify for what disease our patient was under 
treatment, in cases of divorce, or in criminal actions. We have asked 
the opinion of Hon. Otto Pfleger, Judge of the Court of Common 
Pleas in Cincinnati, concerning the privilege of the medical secret be- 
tween physician and patient before the court. His reply is as follows : 
That the relationship between the physician and patient is a sacred 
one and should under all circumstances be protected in law, more so 
than that existing between the lawyer and his client or the priest and 
his confessor, we would all say is axiomatic. It may be necessary for 
a patient to inform his physician of some secret occurrence in order 
to enlighten him and save his life. This, however, is not always true 
of a client to his attorney, and not of a communicant to his priest. 

The common law, which is based on the decisions of the courts 
of England, and of the United States as contradistinguished from laws 
passed by legislative enactment, made communications between an 
attorney and client privileged, but this is not so of communications 
between a physician and a patient. The latter are privileged where the 
legislatures in consideration of public policy have passed special laws 
on that subject forbidding the disclosure in evidence against the will 
of the patient of informations acquired by the physician in his pro- 
fessional capacity. The following States have such a law, — California. 
Colorado, Indiana, Iowa, Kansas, Michigan, Missouri, Montana, Xew 
York, Pennsylvania and Wisconsin. 



SYPHILIS AND MARRIAGE 335 

The State of Ohio, standing alone in this respect, has the following 
law upon its statute book: Sec. 5241. The following persons shall 
not testify in certain respects. 

1. An attorney concerning a communication made to him by his 
client in that relation, or his advice to his client, or a physician con- 
cerning a communication made to him by his patient in that relation, 
or his advice to his patient ; but the attorney or physician may testify 
by express consent of the client or patient ; and if the client or patient 
voluntarily testify, the attorney or physician may be compelled to 
testify on the same subject. 

This law so far as the relation of attorney and client is concerned, 
was construed by the highest courts of the State in i860 to mean that 
this secrecy is a privilege of the client, and that where the client 
voluntarily took the witness stand and gave evidence generally (al- 
though not specifically regarding the confidential communication) he 
lost his privilege, and thereby consented to the examination of his 
attorney and of himself touching any admission made by him. (See 
King vs. Barrett, 11 Ohio State Reports, p. 261.) 

In 1877 the law was again under review in the forgery case of 
Duttenhofer against the State (34 Ohio State Rep. p. 91.) This time 
the court decided that this law did not apply to criminal cases, and 
the common law, making such communications between an attorney 
and client absolutely privileged, unless consented to by the client, would 
be followed. The principle decided in the first case is applicable to 
the relationship of physician and patient. If the patient is a mere 
witness and not a party to the case, the communication is privileged, 
but inasmuch as a physician is seldom called except in cases where 
his patient is one of the parties litigant, and as such patient invariably 
takes the witness stand in his own behalf, it seems there is practically 
no protection in Ohio, for either the patient or his physician in a civil 
proceeding. 

To give this matter a practical test in the courts would require 
much courage on the part of a physician, because his refusal to answer 
would amount to a contempt of court in interfering with the adminis- 
tration of justice, and would result in a fine and possible imprison- 
ment. Perhaps a martyr to the cause may some day be found. There 
is at least room for proper legislation on this subject. 

In divorce cases, for instance, no expedient has any value ; before 
the court we must answer yes or no, or be sent to jail. In these 
cases the defendant is placed on the stand and testifies himself on his 
condition, and he has to open his secret himself, so that it would be 
of no benefit in the case for the physician to remain obstinate in his 
silence. 



336 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

We thoroughly understand the importance of the medical secret, 
we respect it and maintain it as the highest duty, but we find that in 
particular circumstances, when the health of others is involved, and 
in cases where the administration of justice shall require, this medical 
secret is bound to be revealed. 

PROFESSIONAL ETHICS WITH SYPHILITIC PATIEXTS 

Another question arises in reference to the ethics of the physician 
towards his patient. All questions of this kind are difficult to trace 
and their solution rests rather with the personal tact of the physician 
than with his professional knowledge. When we make the diagnosis 
of syphilis, and we tell the gentleman or lady that he or she is affected 
with the dreaded disease, this creates an embarrassing position, which 
is connected not only with the present, but also with the future of the 
patient. 

In the hospital service and in the public clinics we do not care 
much for ethical rules ; we dictate the diagnosis to the assistant physi- 
cian and we limit ourselves to telling the patient, " you have syphilis, 
you must be careful because you may infect anyone who comes into 
contact with you or with objects which you have used, such as pipes, 
glasses, spoons, etc." 

In private practice the condition is very different and the question 
may still arise, " Shall the patient be informed that he or she has 
syphilis?" (Klotz.) X1 

Under ordinary circumstances it is our strict duty to inform the 
patient of his disease, so as to place him on guard against the con- 
tagiousness of the affection, especially in the early stages. Further- 
more, we need the co-operation of the patient for the continuance of 
the treatment, and also for the abandonment of some habits, such as 
the use of tobacco and intoxicants, which when retained usually have 
a disastrous influence on his future. Truth is necessary to inspire 
confidence in our patient, and if truth is withheld even for a reasonable 
purpose, the idea of deception may shake the reliance of the patient in 
the word of the physician. 

In some cases, however, taking into consideration the nervous 

sensibility of the patient, the circumstances in which he is placed, we 

may deem it wiser to withhold our diagnosis for a time until the 

patient is better prepared for the real situation. Many have a horror 

of the disease and the idea of the possibility of causing or of having 

caused infection in others may lead them to some rash act. Fournier 

has already referred to a long list of suicides as a consequence of 

syphilis. 

11 Klotz. " A System of Genito-urinary Diseases," etc. " Syphilology," 
1893, p. 683. 



SYPHILIS AND MARRIAGE 337 

In the case of a nervous patient, where the idea of syphilis would 
cause a deep and sad impression, we believe with Klotz, that it is 
better to give to the patient the benefit of the doubt. We can point to 
the possibility of an infection, and later on, when the patient is better 
prepared, he will be informed of the real condition. 

As long as the patient is responsible only to himself for his 
acquired trouble, our position towards the patient is not so difficult ; 
but when the party is married, then our position is more delicate and 
difficult. It must always be remembered that there is the possibility 
of an accidental infection, and we must regard our patient just as if 
he had been infected without culpability. 

The most important point for the physician is to instruct the 
patient as to the contagious nature of the disease, so as to save others 
from being infected. In the case of a wife who has been infected by 
her husband, when the plain truth would bring trouble into the family, 
we prefer to leave her in ignorance of her condition, not for the 
purpose of shielding the guilty party, but for the sake of peace. When 
infection has taken place we believe it will be of no advantage to a 
woman to know that her disease has been communicated to her by her 
husband, and cause quarrels and lawsuits in the family. Quite often 
we have pointed out the infectious nature of the disease, and the pos- 
sibility of transmission, but we have withheld the name of the disease, 
to keep things quiet. 

In case of hereditary syphilis we believe much more in withhold- 
ing the name of the disease, rather than in destroying the confidence 
and the love of the children towards their parents. 

The physician has no right to constitute himself a judge of the 
morality of his patient, and although the patient has acquired syphilis 
as a result of his own indiscretion, it is not right for the physician to 
consider him as a criminal. The man infected with syphilis, although 
through culpable exposure, is a sick man and he is entitled to the same 
care and to the same attention as patients affected with other diseases. 

It is inhuman and cruel of some religious people who are striving 
to deny admittance into the hospitals to patients affected with syphilis, 
on the plea that the disease is the result of indiscretion. This is the 
result of their ignorance, because they will admit into the hospital a 
. patient paralyzed on account of cerebral syphilis, and deny treatment 
to a patient with syphilis in the secondary period. A few weeks' treat- 
ment in the secondary stage of syphilis would have prevented cerebral 
syphilis and that patient would never have had to occupy that bed in 
the hospital for a long time under medical service. 

Diseases which are the result of indiscretions are many, and if 
these are admitted into the hospitals, syphilitic patients must enjoy the 



338 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

same rights. One of the most powerful means of checking the spread- 
ing of syphilis is the isolation of the patients, and when we can have 
a syphilitic patient in the hospital, it is a great gain in this direction. 
A well-directed treatment for a syphilitic patient, administered in the 
hospital at the beginning of the secondary period, will, we are certain, 
save many months of treatment later on when tertiary symptoms will 
develop. A ward in the hospital for syphilitic patients is a necessity, 
and will be of great benefit for the prevention of the spreading of the 
infection, and for diminishing the ravages of tertiary syphilis. 



SYPHILIS IN REFERENCE TO MARRIAGE AND TO FAMILY 

The fact that syphilis is transmitted from the parents as a sad 
heredity to their children has been universally accepted only in recent 
times. Many have denied the transmission of syphilis by heredity, and 
Kluge 12 admitted that syphilis from the mother passes to the child 
only when the genitals are affected with chancres or ulcerations, and 
the babe became in this way inoculated. 

Hunter maintained that syphilitic infection of the offspring in 
utero was possible only when the mother was affected with syphilis, 
and he denied the transmission of syphilis by heredity when the fathei 
was suffering with secondary syphilis, and the mother remained still 
healthy. Hunter, however, believed that only the pus of the initial 
chancre was capable of transmitting the disease, which through the 
blood vessels of the placenta was carried to the fetus. 

While Hunter admitted the possibility of the infection of the fetus 
from the mother, and denied the transmission of syphilis from the 
father, Swediaur 13 maintained that syphilis could be transmitted from 
the father to the fetus through the semen, but did not mention the 
fact 'of the transmission of syphilis from the mother. 

Ricord and his followers, although they denied the inoculability 
of syphilis through the blood and purulent secretions from a syphilitic 
patient, yet they admitted the transmission of syphilis to the offspring 
from both sides, either from the father or from the infected mother. 

In most of the cases of the children carrying with them this sad 
heritage from the uterus, the affection must be recognized as coming 
from the father. Montanier maintained that some men affected with 
latent syphilis communicate the disease to the wife, without finding in 
the woman traces where the virus has found its entrance into the 

12 Behrend. Archiv fur Syphilis und Hautkrank. Berlin, 1846, 1st B. 1st 
Heft. 

13 Swediaur. " Traite complet des maladies syphilitiques," par Swediaar. 
Paris, 1801. 



SYPHILIS AND MARRIAGE 339 

system. The same opinion was expressed by Cullerier, Simonet and 
Oewre, that syphilis from the father is transmitted to the offspring 
through the mother. 

Drysdale, however, found that this assertion did not correspond 
to his experience, but agrees with the fact that when the mother is 
affected with syphilis the children are more certain to be affected with 
congenital syphilis. 

Zeissl is of the opinion that men affected with syphilis can generate 
syphilitic children while the mother remains apparently healthy. He 
has found that this immunity is only apparent, as he had often occasion 
to observe those ladies married to men still suffering with so-called 
latent syphilis to lose their former fresh and healthy color, and although 
they have no children, they assume a chloro-anemic appearance, their 
glands become swollen, they complain of sternal neuralgia, in a word, 
they have symptoms of syphilis and only a well-directed antisyphilitic 
treatment can help them. 

The fear of the transmission of the syphilitic infection to wife and 
family has to-day spread in all classes of men, so that everyone who 
has been infected is interested to know what the chances are of trans- 
mitting syphilis in case of marriage. 

Henrick Ibsen had the courage to show in his magnificent drama, 
" The Ghosts," young Oswald ill and suffering, who has learned from 
his physician the sad truth that he has syphilis of the brain as sad 
inheritance from his dissipated father. 

If a man affected with syphilis in its early stage, with secondary 
eruption, should get married, he is a criminal and ought to be punished 
for his offense. There is no doubt that his wife will be affected with 
syphilis in the same way as this disease is ordinarily acquired. 

A poor woman affected with syphilis and a gonorrheal endome- 
tritis, contracted from her husband, was innocently asking the following 
question : " Doctor, can you tell me how it is that a girl soon after 
she is married has to suffer so much with her womb, and with her 
general health? I can say that since the first days of my married life 
I have never had a day when I have felt well. This experience is not 
mine alone, but other girls, my schoolmates, healthy and strong as I 
was, after marrying have suffered and are suffering just as I am." 

The reader will understand that the answer which we could give in 
that case was such a one as would have only a palliative effect. We 
found it much better to conceal the cruel truth from her, because it 
was too hard to tell her plainly that her husband, infected with loath- 
some diseases, the result of his dissipation, had infected her, and she 
was suffering on his account. To have taken her from her innocent 
ignorance would have aroused ill feeling and quarrels in the family. 



340 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 



We thought it better to evade the question and let her be happy in her 
ignorance, advising her to continue her treatment. 

Our interest is directed to those persons who have once been af- 
fected with syphilis and have undergone a good and sufficient treat- 
ment. They have seen no more symptoms of active syphilis, they 
wish to enter married life, and they want to know if they can get 
married, not only without any fear of infecting the wife, but also 
without fear of having children affected with hereditary syphilis. 

Indeed, the relations of syphilis to marriage are of the greatest 
importance, as they involve pathological consequences which not only 
affect the interest of the family, but also society at large. The spread- 
ing of syphilis happens not only by the act of intersexual relation, but 
it can be introduced in a subdolous way, as happens through conception. 
Syphilis makes marriage unhappy. The idea of easily getting sick, 
the recurrence of rheumatoid affections, of ulcerated gummata, al- 
though of a superficial type, make life tiresome and gloomy. When 
infection has been communicated to the wife any symptom which may 
occur is a cause of regret and of grief. It destroys the mutual love 
and esteem between husband and wife which is the necessary founda- 
tion of marriage. 

Syphilis is not only capable of destroying the fetus in utero, or of 
showing up in the offspring in all its forms, but transmits a defective 
organization ; the infant comes into this life lacking in development, 
stamped with inferiority. So that Morrow 14 wisely remarks that syph- 
ilis is not only a factor of depopulation, but a cause of degeneration 
of the race. We will not be accused of pessimism if we say that 
syphilis increases a great deal the egotism, which is a sign of decay. 
This unnatural selfishness is a consequence of the exhaustion of the 
vitality of the species as well as of the individual, hence the family 
instinct dies out. 

The question is a very vital one, as there is nothing more im- 
portant than the perpetuation of the race, and syphilis kills the product 
of love, or stains it with its filthy poison in order to make the offspring 
sickly and hideous. The wish for the companionship of a person of 
the other sex, which naturally arises from the impulse of procreation, 
is dulled and decreased by the idea of being infected with svphilis. 
When a married man has been affected with syphilis, he is often sad 
and gloomy in his thoughts and cannot be a pleasant and congenial 
companion. In highly cultured classes of society, where instruction 
and education have attained a great development, the sexual impulse 
becomes exclusive and discriminating, which is the reason why the 
offspring come full of vitality and energy. It is thus that marriage, 
14 Morrow, P. A. " Social Diseases and Marriage." 1904, p. 182. 



SYPHILIS AND MARRIAGE 



341 



as Nordau 15 says, the only relationship between man and woman coun- 
tenanced by society in which offspring are produced, should be the 
result of love. Love is the great regulator of the life of the race, the 
impelling force which promotes the perfecting of the species and pre- 
vents its physical decay. When the thought of the possible infection 
of the wife or of the offspring is weighing on the conscience of a man, 
the mutual attraction cannot be sincere and cordial. There is a mental 
flaw, which will be revealed in the future of the offspring. The chil- 
dren, if they escape infection, will inherit the faults of the parents, 
probably increased, and their good qualities will be modified or probably 
lacking. When infection takes place, although in a very mild form, 
the children sickly and tainted, show signs of a poor and miserable 
generation. This will produce children belonging to that class known 
as not only degenerates, but also as perverted. 

The idea of syphilis in the family which has been introduced by 
the father will always remain as a tormenting thought, which on 
occasion of any little indisposition of the children or of the wife is 
renewed, and it will mar the family life with a sorrowful unrest. It 
is impossible for a woman to forget that one of the first presents she 
received from her husband was a disease, and no matter what social 
rank he may have given to her, no matter what dresses and ornaments, 
she cannot have any esteem, much less love, for such a companion. 
The woman is in every way the victim, who is infected either directly 
or indirectly through conception. 

The man, when destitute of the courage to assume the responsi- 
bility of having a family, fearing that the disease may manifest itself 
in his children, concludes to remain unmarried. He will remain a 
confirmed old bachelor. 

In all these cases the physician plays an interesting role. He has 
to deal with vital problems which reflect on society from a physical 
and moral standpoint. It is his task to stop a marriage by his veto, 
or it falls to him to allow the marriage. A great responsibility weig-hs 
upon him, for from the solution of these problems depends the happi- 
ness and the future of a family. 

The idea that syphilis cannot be cured is a great mistake, and 
equally wrong is that idea that as a consequence the man who has been 
once infected must never get married. We have seen that syphilis is 
curable and it is permanently cured. In our rather long practice we 
have had occasion to treat many young men infected with syphilis. 
who after a period of some years have married, and neither they nor 
their wives have shown signs of the disease, and their families are 
healthy and happy. In this regard A. Fournier 16 is right when he 

15 Nordau, Max. " Conventional Lies of our Civilization," p. 277. 

16 Fournier, A. " Syphilis et manage." Paris, 1890, p. 20. 



342 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

reproaches his colleagues, who have entertained such gloomy ideas 
in reference to the marriage of syphilitic persons, as absolutely to 
forbid them to marry, under the assertion that " when a man has 
unfortunately contracted syphilis, he must keep it for himself, and 
never expose his wife and children to the danger of this disease." 
Such an assertion we find without foundation and without a scientific 
basis, and we accept that of Fournier, which agrees with our expe- 
rience, that " when a man has syphilis, he must strive to get well, and 
when through a continuous treatment the disease has been rendered 
harmless for himself and for others, then he can re-enter the ordinary 
conditions of life and he can aspire to marriage." 

Indeed, syphilis does not constitute a permanent impediment to 
marriage, but it entails only a temporary interdiction. After a certain 
period of treatment the disease gradually dies out, the man returns to 
his normal condition of health, and he can without fear have a wife 
and children. 

Fournier refers to the observation of eighty-seven young men who 
had been infected with syphilis and who after a rational treatment of 
regular duration have married and have never communicated any 
suspicious symptom to their wives, and in a total of 156 children no 
traces of syphilis could be found. 

Consequently a man who has once been infected with syphilis can 
get married, but he has many conditions to comply with, and only after 
the fulfillment of them can he obtain a clean patent and enter married 
life. 

It is necessary, therefore, to exactly establish these conditions, 
which when neglected will expose to danger of infection the wife and 
the family. As we have seen in other chapters, it is not the question 
of time alone, but it is a question of undergoing a strong and heroic 
treatment. Without these two essentials of a certain period of time 
having elapsed from the infection, and of a regular specific treatment, 
the .man who has had syphilis, on entering married life becomes a 
danger for his wife, for his children, and for the community. 



II 

SYPHILIS IN RELATION TO DEGENERACY 

Syphilis is capable of producing malformations and anatomical 
deviations from the normal development and of degrading the un- 
fortunate descendants. We have already seen stigmata consisting in 
facial asymmetry, deformities of the palate, anomalies of the teeth, 
hare-lip, peculiar shape of the nose, all to be connected with a syphilitic 
parentage. It is now of vital interest to study the part which syphilis 
takes in anomalies and in disturbed or retarded development of the 
functions of the nervous system. These anomalies and any arrest of 
development must not be considered as direct syphilitic manifestations, 
but they are rather the result of the effect of the syphilitic taint on 
the blood and also on the lymph vessels causing these affections. In 
other chapters we have already mentioned the important anatomo- 
pathological alterations produced in the blood vessels from the be- 
ginning of the hard chancre to the formation of gummatous produc- 
tions. These alterations in the adventitia and much more in the intima 
of the vessels are so characteristic, that from the condition of their 
tunics the anatomo-pathological diagnosis of syphilis can be easily 
established. In many cases of children affected with hereditary syphilis 
we have found the same hyperplastic condition of the tunics of the 
blood vessels in different organs which did not show macroscopic 
pathological lesions. 

In order to gradually enter into the discussion of so important a 
subject we will refer to a case which has greatly impressed us in our 
practice. In 1886 we were treating a patient for ulcers of both legs. 
He was a young man, twenty-two years old, of rather delicate physique, 
had never acquired syphilis and had enjoyed rather good health. The 
ulcers of the legs, multiple, circumscribed, in a kidney-shaped disposi- 
tion, suggested a possible specific origin. Applications of mercurial 
plaster and large doses of potassium iodid cured the ulcers. While 
under treatment we had occasion to see the father of our patient for 
some trouble and we found that he showed unmistakable symptoms of 
acquired syphilis. For several years we lost sight of the patient, when 
he came to consult us in regard to his daughter, a little girl of eight, 
who was suffering with convulsions, which had been diagnosed by 
every physician as epileptic, and for which nobody had been able to do 
anything. 

343 



344 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The little girl was of a rather weak constitution, but of a bright 
intelligence. Her skin was dry and of a yellowish hue. Connecting 
the links of the history of her grandfather, and of the ulcers of the 
legs of her father, it was not difficult to find the indication of a specific 
treatment. Under this treatment the epileptic attacks have disappeared 
and the girl is enjoying good health. 

We have already had occasion to mention a case of a family where 
the father was healthy, but the mother had been affected with syphilis 
when a young girl. She had nine pregnancies in succession which 
resulted in abortions and dead children. Finally after undergoing 
severe antisyphilitic treatment during pregnancy, she gave birth to a 
healthy child. It was a boy who remained well until the age of five, 
when he was taken with spasms. It was a clear case of Jacksonian 
epilepsy, the attacks beginning from the left leg. The boy was treated 
with inunctions with mercurial ointment, and internally with large 
doses of iodide of potassium. The attacks have disappeared and since 
then the boy has always been well, is attending school and shows him- 
self to be rather intelligent. 

Epilepsy is not a syphilitic affection, it is rather a symptom of 
cerebral disturbance, although many neurologists are inclined to con- 
sider it as a pure neurosis without recognizable lesion. Chaslin stated 
that he had found in true epilepsy sclerosis of the neuroglia of the 
convolutions, an alteration which he called gliosis, and which would 
prove to be a congenital malformation of the external layer of the 
blastoderm, and could be connected with a heredo-syphilitic parentage. 

Partial epilepsy described so well by Hughlings Jackson forms a 
portion of the symptomatic syndrome of an acute or chronic form of 
meningitis. Syphilis is one of the most important etiological factors, 
and it is universally admitted that the presence of gummatous forma- 
tions in the meninges or in the brain produce this peculiar form of 
partial epilepsy. It is, however, a parasyphilitic affection, because it 
is produced in the same way by traumatism, fractures with depression 
on the cerebral cortex, and is a valuable sign in the case of surgical 
interference. 

It has been found in persons who had been previously attacked 
with hemiplegia or partial paralysis, which must be considered as the 
result of cerebral lesion from alteration of the blood vessels. These 
alterations in most of the cases result from the condition of the tunics, 
and of the interior of the blood vessels induced by syphilis. The at- 
tack is exactly the same, if produced by syphilis or if resulting from 
any other cause, but on many occasions the antisyphilitic treatment has 
been of great benefit to the sufferers. 

In partial epilepsy the attack is often preceded by some sensation 



SYPHILIS IN RELATION TO DEGENERACY 345 

of pain, cold, or numbness in the limb where the initial spasm takes 
place. These alterations of sensation are to be considered like the aura 
epileptica. In partial epilepsy in some cases the patient does not lose 
consciousness and the attack remains strictly partial. It may begin 
from the face, the spasms starting from an eye or from the mouth and 
then spreading to the rest of the face with contractions of the eyelids, 
of the lips, of the muscle levator alae nasi, gnashing of the teeth, ex- 
tending at times to the muscles of the neck. 

When the attack commences from the extremities, it is the thumb 
and the index finger, or the great toe, which are flexed convulsively, and 
from them the spasms extend to the arm or to the leg. The greater 
or less spreading of the spasm causes great difference in the clinical 
appearance of the attack, so that in some cases, although it begins as 
partial in one extremity, it spreads to the whole body with loss of con- 
sciousness. In some cases after the attack of partial epilepsy there 
remains a weakness in the affected muscles, which at times may reach 
the degree of transitory paralysis, and even disturbances of speech, 
stammering, paraphasia and true aphasia. These conditions are more 
liable to appear after the attacks of partial epilepsy than after general 
epilepsy. Usually in this affection the attacks begin on the same side 
and in the same group of muscles. 

In this connection we find it of some interest to refer to a case of 
ophthalmic migraine, which was greatly benefited by an antisyphilitic 
treatment. The patient was a man of forty, of rather dull perception, 
but well educated. He showed a strange conformation of the skull, 
cranium nati forme, and his right hand and arm were weak and poorly 
developed on account of infantile paralysis, which he remembered in 
his early youth, associated with recurrent spasms. He was afflicted 
with attacks of violent pains in the left half of his head and face, 
accompanied with scintillating scotoma, which lasted for some time, 
then a period of exhaustion followed and he fell into a somnolence 
which lasted for a few hours. 

There was no doubt that the affection was one of ophthalmic 
migraine. The most persisent and dreaded symptoms were : the flash 
of light which he used to see at the beginning of each attack ; the 
violent headache, hemianopsia, and vertigo, which was followed by 
nausea and vomiting. The gentleman could not even raise his head 
from the pillow for fear of vertigo and of the flash of light, which 
he dreaded. 

We had never had occasion to see his parents or relatives ; his 
father was living in Italy, as were also two brothers, but nothing 
could be found to enlighten as to the history of the family. From the 
anatomical conformation of the skull, from the appearance and faulty 



346 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

implantation of the teeth, from the history of spasms and hemiplegia 
in his infancy, the diagnosis of syphilis in the second or third genera- 
tion was justifiable. 

Our diagnosis, after a while, found good support in the result 
which we obtained when he was subjected to severe specific treatment. 
At present he has fully recovered, is attending to his occupations, and 
has never been troubled since. 

There is no doubt that his affection consisted in a partial epilepsy, 
produced by the condition of the blood vessels, induced by an inherited 
syphilitic taint. Like convulsive partial epilepsy, ophthalmic migraine 
at times occurs in a serial form, recurring several days in succession. 
In some cases the attacks are of an intermittent type and terminate in 
a period of stupor. 

In another patient, who had been luetic for years, there occurred 
attacks of ophthalmic migraine, which were followed by ptosis of the 
right eyelid. He gradually improved as far as the migraine was con- 
cerned, and began to raise the eyelid, which remained somewhat lower 
than the other. At the time of the attack of migraine he complained, 
not only of the flash of light in his right eye, but also of a loud noise 
in the ear of the same side. 

He was after a while seized with an apoplectic stroke, from which 
he recovered, leaving paralysis of the left arm associated with partial 
asphyxia of the fingers and hand, showing that the vasomotor nerves 
had been involved in the same process. 

In some cases one of the sterno-cleido-mastoid muscles has re- 
mained contracted, drawing the head away from the painful side. 
Ophthalmic migraine, although it has been considered as an accident 
of not much gravity, is nevertheless an ominous sign, which when con- 
nected with arterio-sclerosis may produce permanent paralysis, which 
will persist as monoplegias or hemiplegias, and even as diplegias, some- 
times with a fatal termination. 

We agree with the opinions expressed by Jullien, Tommasoli, Fere 
and others, that hereditary syphilis is an important factor in the causa- 
tion of epilepsy in children. A long list of different causes of epilepsy 
has been given, and Esquirol, Morel and Lucas have maintained that 
the influence of drunkenness at the moment of conception has a great 
influence in the production of epilepsy. Others have enumerated as 
its causes the use of the forceps at the moment of delivery, the long 
retention of the head in the pelvic cavity, the placing of the infant 
always on the same side, etc. 

Brown-Sequard 1 and Fere 2 have attached a great deal of im- 

1 Brown-Sequard. Archiv. de Physiologie, 189 1. 

2 Fere, Chas. " Les epilepsies et les epileptiques." 1890. 



SYPHILIS IN RELATION TO DEGENERACY 347 

portance to a neuropathic taint transmitted from the parents to their 
children in the form of convulsions. Fere referred to the case of a 
man who in consequence of a trauma became epileptic, and had a 
daughter who at the age of five was affected with epilepsy. 

These observations, however, do not exclude the fact that syphilis 
is one of the most powerful factors in the production of epilepsy. 
Syphilis may cause convulsive attacks as poison in the secondary stage, 
without causing any anatomical lesion. We remember in our practice 
a girl of a Syrian family who contracted syphilis. At the first eruptive 
period she was seized with epileptic fits. As the syphilitic symptoms 
diminished in their intensity, the frequency and the severity of the 
convulsions gradually diminished. 

It is also possible that pre-existing epilepsy may be aggravated by 
acquiring syphilitic infection, and in this case antisyphilitic treatment 
will be of great advantage in cases of epilepsy. Fournier has estab- 
lished a para-syphilitic epilepsy, to which he could not assign any char- 
acteristic feature, nor any special type. During the tertiary stage of 
syphilis, epilepsy shows itself with some frequency. In these cases 
there is no doubt that epilepsy is the result of syphilitic lesions on the 
nervous tissue, such as the formation of a gumma, erosions of the 
cranial bones, specific inflammation of the meninges, alterations of the 
blood vessels. 

In our service in the City Hospital we remember a patient who was 
affected with an ulcerated gumma of the left knee, who had never 
before suffered with epilepsy, and in the ward he was attacked with 
several epileptic fits. Under an antisyphilitic treatment the ulcer of the 
knee was brought to recovery. 

By means of a prolonged antisyphilitic medication we obtained 
gratifying results in an Italian who had been epileptic for many years. 
He was a man with a peculiar conformation of the skull, with an 
asymmetric appearance of the parietal eminences and a pronounced 
protrusion of the frontal bone. His nose was somewhat sunken under 
the glabella, his teeth were irregular and decayed. Although he showed 
no signs to certify the presence of syphilis, yet from the malformations 
referred to we had every reason to suspect an hereditary syphilitic 
taint to be at the bottom of his sufferings. 

He suffered with minor attacks, petit mal, usually at night time, 
he was aware of the coming attack, as he woke up just before being 
affected. The attacks were so frequent as to recur twice in the same 
night. The man had no rest, he felt tired and despondent, as he felt 
himself unfit in the day time to attend to his occupation. ' 

With an active antisyphilitic treatment, consisting of subcutaneous 
injections of gray oil fifty per cent., and of iodipin, the attacks began to 



348 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

diminish, so that for a while they were limited to one a week. Gradu- 
ally he improved so much that the last time he was seen he had not had 
any attack for over six weeks, he slept soundly, attended cheerfully 
to his occupation, and had gained considerably in weight. 

The case cannot be considered as an absolute cure, but we find the 
results to be very gratifying. 

Inherited syphilis, although in some cases it may produce epilepsy 
by anatomo-pathological alterations induced on the tissues, yet in most 
of them it only prepares the ground for the development of the dis- 
ease. According to Gowers 3 the affection which excites the convul- 
sions is most frequently at the cortex, and when an organic disease 
causes convulsions beginning at a certain locality, the disease is in- 
variably at the cortex. For this reason epilepsy is produced by any 
morbid affection of the gray matter of the cortex, and in some cases, 
as referred to by Fere and Chaslin, it is produced by a diffuse sclerosis 
of the neuroglia. 

We have dwelt somewhat on epilepsy for the reason that, in many 
cases, syphilis is the cause of the disease, or if not the direct one, one 
of the predisposing factors. There is no doubt that epilepsy produces 
a degeneration of the mind, and an epileptic has a psychical condition 
of his own. 

There are incomplete or aborted manifestations of epilepsy, which 
have been described as mental vacuity, which is a momentary sus- 
pension of the psychical functions, without convulsions. Besides this 
mental vacuity with inactivity of the intellectual faculty a dullness is 
associated with impulses, which makes the epileptic sometimes danger- 
ous to his family and to society. 

These mental disturbances may precede or follow a convulsive 
attack, but in some cases a kind of vertigo constitutes of itself the 
paroxysm equivalent to a psychical attack, which Maudsley compares 
to a mental convulsion. Under the influence of this attack, the patient 
is capable of exhibiting rude behavior, of damaging objects and even 
striking or killing people. Other patients may commit indecent acts, 
of which they do not retain any recollection, falling after a while into 
a state of prostration or into an epileptic fit. 

This state of vacuity of mind associated with impulses is usually 
of short duration, but at times may last for several hours, and Charcot 
has found it to last to the extent of one week. In this case the 
epileptic is capable of committing crimes necessitating a complexity of 
acts, such as theft, arson, etc. In their acts, the epileptics in this state 
of psychical condition, do not show anything to attract attention, on 
the contrary their actions appear reasonable and justified. The danger 
3 Gowers. " Diseases of the Nervous System." 



SYPHILIS IN RELATION TO DEGENERACY 349 

usually comes from the hallucinations of a terrifying nature, to which 
the patient is subject and under which he receives the dreaded im- 
pulses. 

Of course, in the whole act committed by an epileptic under the 
mental attack, there is something characteristic which makes it distin- 
guished from a criminal act feloniously committed. The impulsive 
act of an epileptic is sudden and independent of the ordinary circum- 
stances ; it is preceded by an irregular state of mind, restlessness, irri- 
tability. The act is constantly of the same kind, and always done in a 
like manner. Furthermore, in case of violence, there is a larger 
amount of force displayed than is necessary ; for instance, in a case of 
murder, the victim will be found with the head entirely severed from 
the body, or covered with wounds from head to foot, as the epileptic 
throws himself fiercely against the cadaver. 

The paroxysm ceases suddenly and it is followed by depression, 
the same debility which succeeds a convulsive crisis. The epileptic 
does not recollect anything of the act committed during the impulsion 
and unconsciousness is the characteristic of the delirium of the 
epileptic. 

The recurrence of the attacks causes nervous exhaustion, and it 
requires some days for the epileptic to regain the lost hemoglobin and 
to repair his mental activity. In consequence, often-recurring attacks 
cause deterioration of the whole system, the intellect perishes com- 
pletely, and the post-epileptic exhaustion is the cause of the dementia 
which is the end of some of these unfortunates. 

We can say that the moral and intellectual faculties in the epileptics 
usually are not so very well balanced. There is always something 
extravagant in the acting and in the talking of epileptics, at times they 
are easily excitable, at times they are sad and depressed. In a moment, 
from the sentiments of generosity and of jovial expansion, they fall to 
the opposite extreme of gloominess, jealousy and despondency. Under 
this depression and despondency, with the consciousness of inferiority 
and of impotence, the suicidal impulse sometimes arises. Their fre- 
quent hallucinations and terrifying dreams, to which they are subject, 
make them timorous and suspicious. Their mental oscillations are 
often the cause of remittent or circular insanity. 

In the epileptic, as a rule, the memory is often weak, perception 
is rather difficult, and conception is somewhat slow. In some epileptics 
occurs a sudden lighting up of the intelligence in the form of hyper- 
amnesia or hyperideation, which may last several hours or even some 
days preceding the paroxysm, but it is always followed by mental 
depression. 

Gradually the epileptic, with the repeated attacks, falls into 



350 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

epileptic dementia. It has been stated that epilepsy is frequently 
associated with idiocy in such proportions that one-third of all idiots 
are epileptics. On the other hand, we find also a fair number of 
epileptics who do not show any sign of degeneracy. On the contrary, 
we know of great men who have suffered with epileptic attacks, and 
yet they have distinguished themselves in literary works. 

Anomalies in the epileptics may be found when epilepsy has begun 
at a very early period of life, and in these cases morphological or 
functional abnormalities may be present to show the intensity of the 
predisposition. 

Dumas de Montpellier 4 noted as an abnormality in epileptics the 
inferiority of the facial angle, Solbrig the narrowness and deformity 
of the vertebral canal. Lasegue laid great stress on the cranial, 
asymmetry, which he considered a constant abnormality in true epilep- 
tics. He considered epilepsy to be the result of malformations of the 
cranial bones which had taken place at the period of the ossification. 
Although this statement is entirely exaggerated, yet we cannot deny 
that cranio-facial asymmetry is often found associated with epilepsy. 

According to Fere the asymmetry affects the cranium and the 
face at the same time. It may be found that the frontal eminence is 
less marked on one side, or the parietal eminence is too prominent, the 
orbit less wide. In some cases, deviation of the nose gives a peculiar 
appearance to the lines of the face, while in other cases the inferior 
maxilla is shorter and the teeth are badly placed. Quite often the 
vault of the palate has been found highly arched. Among the cranial 
deformities we find at times a relative increase of one of the diameters, 
the vertical, forming sugar-loaf head, or an increase or diminution of 
the other diameters in the form of macrocephaly or microcephaly. 

Malformations have been found not only on the face and cranium, 
but also on other parts of the skeleton, as asymmetries of the thorax, 
of the pelvis, unequal length of the extremities, abnormal length of the 
fingers, polydactylism, syndactylism, etc. In the same way anomalies 
have been found in the eyes, as different colors of the irides, asymmetry 
of the pupils, deformity of the auricles, anomaly of the genital organs. 

It seems that the general nutrition in the epileptic is often im- 
paired. Bean remarked that epileptic girls menstruated later, and 
often showed signs of general disturbances and weariness. These 
stigmata are not found in all epileptics, but they are quite developed in 
hereditary epilepsy. 

The reader has already noted that these stigmata which have been 
found in epileptics, are just the same as we have found in heredo- 
syphilitic subjects. The organic deterioration of the epileptic can, 
4 Quoted by Fere. " Twentieth Century Practice," Vol. x. 



SYPHILIS IN RELATION TO. DEGENERACY 351 

therefore, be attributed without doubt to syphilis in the parents. Of 
this opinion we find Jacobi, who stated that many cases of epilepsy can 
be traced to inherited syphilis, and Holt, 5 who stated that syphilis may 
be the cause of epilepsy even when there is no local disease of the 
brain. In fact, persistent malnutrition of the infant, in spite of proper 
food and hygiene, is very suggestive of congenital syphilis. Hanson 6 
said that he had no doubt that epilepsy may have its origin in the mal- 
nutrition of the second stage of acquired syphilis, while local endo- 
cranial diseases come later in the luetic history and are usually due to 
chronic inflammation or meningeal growths. Cases of epilepsy origi- 
nating from hereditary syphilis, according to Hanson, would develop 
later than those due to alcoholism. In the same way cases due to 
cranial asymmetry rarely begin after the eighteenth year. Epilepsy 
is often related to other defective mental conditions of pupils, which 
are unfortunately often brought to the attention of the sufferers by 
their teachers and by their companions with taunts and even with 
rebukes. .These conditions of association do not improve the capabili- 
ties, which could otherwise be developed, and they grow more reserved 
and timid, and sometimes spiteful and suspicious. 

Feeble-minded children are divided by Noyes into: 

1. Those in whom the faculty of perception is deficient, as the 
deaf and blind. 

2. Those having the special senses, but lacking the power of 
attention. 

3. Those showing defects or diseases of will. 

4. Those showing defects of reasoning power. 

5. Those who are morally defective. 

We must not believe that syphilis is a general cause of epilepsy, 
but in a great many cases hereditary syphilis may be, if not the cause 
proxima, at least the predisposing cause of epilepsy. In many cases 
syphilis may act as a toxic element, like alcohol and lead poisoning, 
which in a neuropathic individual are capable of causing epileptic 
attacks. In other cases it may produce an irritative condition of the 
nervous cells on account of the condition of the lymph and blood 
vessels, which are so much changed on account of syphilis. In these 
conditions it is possible, as Esquirol, Morel, Lucas and others have 
maintained, that drunkenness of the parents in the moment of concep- 
tion may be of an injurious result on the nervous system of the off- 
spring, and epilepsy be the consequence. But when the condition of 
the blood and lymph vessels are such as to impair the development and 

5 Holt. " The Diseases of Infancy and Childhood." L. Emmett Holt. New 
York, 1897. 

6 Hanson. " Etiology and Propylaxis of Epilepsy." D. S. Hanson, Pedi- 
atrics, vol. xiv, No. s, 1902. 



352 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

the nutrition of the neuron, we will find that syphilis will act as a 
primary predisposing cause, and drunkenness of the parents as the 
exciting cause of the epilepsy in the child. 

DEGENERACY 

It is not rare in our experience to meet and become acquainted, 
or even to enter into ties of friendship, with scientific men, with writers, 
poets, painters, etc., who gradually, under a keen study will reveal 
in their actions or talk some kind of abnormality in their reasoning, or 
some mental faults, which make us consider them in the group of " the 
cranks," as we call them in our American slang. They represent a 
class of people who show the greatest intellectual activity, and are 
able to command the respect and admiration of anyone who comes into 
contact with them. But when associating with them, it is easy to find 
out in their ordinary life, moments of extravagance which reveal 
something wrong or defective in their mental faculties. 

This class of people has been well defined by Nordau with the 
term, " fin de siecle " men, and have been grouped with the dusk of the 
nations. They show some limping point in their ideas and in their 
expressions. One will show some silliness in his conceptions and in his 
judgment, another will show some incoherence in his ideas. One will 
have some intermittance of excitement and depression of his mental 
faculties, while another will show depravity in his tastes and tend- 
encies. One will show himself passionate, irascible over matters of no 
importance, while another will show no emotion in the presence of 
serious events. In all their perceptions and conceptions, they are not 
exactly natural, and in the range of their mental manifestation is a 
kind of disharmony between their intellect and their emotions. A man 
who is not a plrysician finds a sufficient explanation in the terms 
caprice, eccentricity, affectation of novelty, instinct, but a physician 
recognizes in them hysteria, neurasthenia or degeneracy. They are 
degenerate in the sense of Morel, 7 who defined degeneracy as a morbid 
deviation from an original type, which has been accepted by Nordau. 

According to Morel, " this deviation, even if at the outset it was 
ever so slight, contained transmissible elements of such a nature that 
anyone bearing in him the germs, becomes more and more incapable of 
fulfilling his functions in the world " ; and mental progress already 
checked in his own person, finds itself menaced also in his descendants. 

When we inquire into the origin of this debilitation of the human 
race, we must see a pernicious morbid cause, which is capable of under- 

7 Morel. " Traite des degenerescences physiques, intellectuelles et morales 
de l'espece humaine et de causes qui produisent ces varieties maladives." Par 
le Dr. B. A. Morel, Paris, 1857. 



SYPHILIS IN RELATION TO DEGENERACY 353 

mining the constitution, the strength, the health, and the intellectual 
faculties of the affected people. Syphilis, the disease with the poetical 
name, has a great deal to do in the debilitation of the human race, and 
to such an extent that we do not hesitate to say that it is one of the 
most effective causes of degeneracy. We have already seen the 
peculiar deformities and dystrophies to which the descendants from 
syphilitic parents are subject, so characteristic, indeed, that they have 
been denominated stigmata or brand-marks. It is really an unfortunate 
termj as Nordau has remarked, including a false idea of degeneracy 
as if it were the consequence of a fault or the indication of a punish- 
ment. Such stigmata we have already seen consisting in asymmetry, 
or unequal development of the halves of the face and cranium ; imper- 
fection and malformation of the auriculae, which sometimes protrude 
from the head like handles, squint eyes, hare lips, irregularities in the 
form and in the position of the teeth, flat palates, supernumerary 
fingers. All these malformations cannot be explained in other ways 
than by a cause, which acts upon the vascular system, cutting off the 
nutrition with the arrest of development. We can study as much as 
we want, but we will always find syphilis in the developing embryo to 
be the only cause of the vascular alterations producing the referred 
dystrophies. 

If the originators of the fin de siecle movement have in themselves 
some characteristics which make them belong to the class of de- 
generates, very likely a physical examination of their organism will 
reveal a syphilitic hereditary taint. Stigmata, however, are not only 
of a physical nature, but there are some of a mental order, which, as 
we have already mentioned above, give a peculiar idea or some peculiar 
psychical mark to make them recognized as belonging to the degener- 
ates. These persons have already been designated as " borderland 
dwellers," by Maudsley and Ball, as being on the line between reason 
and madness. Magnau called them higher degenerates, and Lom- 
broso, " mattoids," from the Italian word matto, insane. 

The asymmetry which we have found in the face and cranium 
of those individuals is repeated in their mental faculties, of which some 
are nearly stunted, others greatly excited. The degenerate, accord- 
ing to Nordau, has a flaw in the sense of morality and of right and 
wrong. For them there is no law, no decency, no modesty. Some of 
them are capable of committing crimes for the purpose of satisfying 
their impulse or caprice, and without any regret or even notice of 
their offense. These persons, according to Maudsley, are affected 
with moral insanity. But there are others in a lower stage, who do 
not commit any crime, but yet they boast of the theoretical legitimacy 
of the crime. Thev have their own ideas about eood and evil, virtue 



354 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

and vice, which they consider only simple distinctions. They admire 
and speak of the greatness of evil-doers as of heroes, they try to find 
beauty in hideousness, and call attention to every bestiality. In con- 
sequence the psychological stigmata of moral insanity in all its degrees 
are referred to Egoism and Impulsiveness. The person in this condi- 
tion of moral weakness is unable to resist a sudden impulse and com- 
mits any deed for his egoism. 

The emotions in the degenerate are greatly exaggerated, so that 
he will laugh or shed tears for entirely inadequate reasons. He thinks 
his excitability a mark of superiority, and believes himself above the 
others, whom he considers vulgar and narrow-minded. In others, a 
condition of mental weakness and despondency is the prevalent sign of 
degeneracy, they have a vague fear of everybody, they commiserate 
themselves and feel tired of themselves. The sufferer is a melancholic 
one, who is downcast, despairing of himself and of the world, fears 
the unknown, and believes himself menaced by dangers. He touches 
the landmark of the paranoiac. This dejection of the degenerate is 
combined with a disinclination to action due to a lack of will power. 
He, however, has no idea of his incapacity for action, he takes it to be 
a consequence of his own determination and not of a deficiency of his 
brain. He has his own philosophy of renunciation of the world and 
men, he wants quietism and praises the high ideal of the mind. He is 
incapable of concentrating his attention on any subject, and his ideas 
are semi-lucid and blurred, conveyed by defective senses to a dis- 
tracted consciousness. It is impossible for him to have a civil position, 
where steady attention is required, but he ascribes it to his idealism - 
and to his esthetic tendencies. 

A degenerate has also doubts of everything, he studies chimerical 
enterprises, thinks himself a discoverer of the most difficult problems. 
Lombroso refers to these intellectual peculiarities of the degenerates, 
the acts and the writings of revolutionists and anarchists. They find 
themselves unable to live under the existing circumstances, they want 
a morbid variation, as they cannot bear social conditions which impose 
upon them self-control, of which they are incapable on account of 
their lack of will power. In consequence they believe themselves 
reformers of society, they want change of government, and under an 
idea of misunderstood philanthropy they boast or commit absurd and 
monstrous deeds against people, property and community. 

Some of them, as I have stated in the beginning, appear to be 
highly gifted men, and of them Lombroso 8 makes a group which he 
calls superior degenerates, which he considers as an active force in the 
progress of society. This idea, however, is strongly opposed by Nor- 

8 Lombroso. Nouvelle Revue, July 15, 1891. 



SYPHILIS IN RELATION TO DEGENERACY 355 

dau, 9 who follows the opinion of Tarabaut 10 that cranks, wrong- 
headed, unbalanced, incapable creatures, they belong to the class of 
whom it may be said that they have no mind, or whose minds produce 
nothing. They have a characteristic in common, weakness of judg- 
ment associated with an unequal power of intellectual faculties. In 
consequence their ideas are fantastic, dream-like, lacking of subject 
and through the power of a disordinate imagination, are without a 
substantial conception. This forms the principal reason of decadence ; 
in fact, when we take painters, poets and writers of such an age, we 
find brilliant colors wrongly associated, verses rich in rhymes, lacking 
in thoughts, and novels full of hysterical recitals, without aim. and with- 
out conclusion. Such qualities we find in those persons who, al- 
though greatly admired, commanding respect and attention above 
others, yet show some flaw in their mental faculties or in their expres- 
sions, which makes them rank among the mattoids. Another set of 
persons are amazed at their perverted doctrine, admire them in all 
their expressions and doings, and follow them in their extravagances. 
They belong to the same class. 

The unnatural emotionalism which we find in hysterical women 
must also be regarded as a sign of degeneracy, and their psychical im- 
pressionability makes them dangerous to society. The morbid mobility 
of their mind and the excitability of their imagination conveys to their 
mind all sorts of fantastic and senseless ideas, which on account 
of a peculiar suggestive faculty assume the appearance of perceptions, 
and consequently they believe all that foolishness as truth. The in- 
clination to lie, which is so characteristic of hysterical women, does 
not come from their will, but from their excitability and from the false- 
ness of their perceptions. They lie, entirely persuaded of the truth 
of their illusions and hallucinations ; people who are feeble-minded 
admire that kind of fantastic and excitable creatures, they are amazed 
by their vivid and wondrous tales, they are enthused by their fallacious 
and ridiculous doctrines, they become their followers, profess the same 
fantastic ideas, because they are unable to think with their own brains 
and are incapable of sound judgment. They lack good sense, are 
weak-minded people, and find just what they want in those hysterical 
people, forming what Charcot has called, la folie a deux, in which 
a deranged person forces his insane ideas on a companion. 

Lombroso has well remarked that malefactors associate together, 
forming bands, one connected with the other in their misdeeds and in 
their crimes. 

In the study of the etiological factors of degeneracy we find a 

9 L. c, p. 24. 

10 Tarabaut. " Des Rapports de la Degenerescence mentale e de l'Hysterie." 
Paris, 1888. 



356 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

long list of morbid causes alleged as capable of weakening the system 
of persons and make them susceptible to degeneration. Morel traces 
degeneracy to poisons, and find that alcoholic excesses, tobacco, opium, 
badly preserved food, are all capable of producing degeneration in the 
race. Fere attributes the cause of hysteria and neurasthenia, and 
consequently of degeneracy, to the fatigue of the present generation. 
He has very wisely remarked that a normal individual can be easily 
changed into a hysterical one by tiring him; in consequence all these 
forms are to be considered as the result of the depression of vitality. 

Many observers assign an important part in the production of 
degeneracy to the great progress of our era, to the railroads, the travel, 
the vibrations, the accidents, and they even say that all these have made 
a railway spine, a railway brain. To this excitement, when we add the 
enormous increase of the consumption of tobacco and alcohol, we will 
surely agree with the French scholar, Fere, that these conditions have. 
a great relation to the fatigue. The individual who has stood a great 
deal of fatigue or excitement feels exhausted, and that feeling of ex- 
haustion prompts the use of stimulants. The ephemerous euphoria 
which is produced by a drink of whisky is an artificial invigoration of 
only a short duration, in consequence their exhaustion increases the 
weakness of the will and a craving for more whisky which they are 
unable to resist. 

That the tumultuous life, the rush of business, the modern way of 
living, may have some influence in depressing the bodily vitality and 
preparing a new generation having many degenerates, neurasthenic 
and hysterical subjects, nobody can deny; but this we consider only 
as an occasional cause. It is a cause which is found very plausible by 
the generality of the people. Business cares have disturbed this mind, 
failure of success has driven that man crazy. But an observer of 
human nature, a physician, will see that the alleged cause is only an 
occasional one, and he will look for a cause which we call causa 
proxima, the true cause, which has produced histological and patho- 
logical changes of the nerve cells, which in consequence of any 
other occasional cause have manifested their diseased condition. 

The gray surface of the brain is made up of innumerable nerve 
cells, which by their activity constitute intuition. The nerve cell is an 
anatomical unit, as it exists by itself independent of all other tissues. 
It has only contiguity of structure, but no continuity as proved by 
Golgi. A pyramidal cell has two integral parts, the body and the 
process of the cell, which together form the anatomical unit, which is 
now called the neuron. 

The body of the neuron is the seat of the nucleus in which is again 
found the nucleolus. The nucleus is very large, and apparently has a 



SYPHILIS IN RELATION TO DEGENERACY 



357 



nutritive function only. Indeed, if any part of the neuron is cut off 
from the portion containing the nucleus, the remaining portion of the 
neuron will degenerate and die. It seems impossible to unravel the 
complex network into which the cells and fibers are interlaced together ; 
and we can say that the function of each single element is really beyond 
our reach. But we will easily understand that any pathological altera- 
tion or any malformation affecting the connective tissues of the nervous 
system or of its blood vessels must produce great and important 
changes in the functions of those delicate nerve cells. The connec- 
tive tissue binds together the delicate nerve elements, and also 
supports the blood vessels, which perforate the membranes to carry the 
nutrition to the nerve fibers. 

In order that we may explain the different alterations of the 
functions, and the morbid manifestations which result from the 
pathological changes induced by syphilis in the connective tissues and 
in the lymph and blood vessels of the nervous system, it will be useful 
to recall the functions of the nerve cells in their psychical activity. The 
circulation of the blood in the skull is so protected that it is not sub- 
ject to differences of pressure or of resistance from the external world. 
The quantity of blood enclosed in the cranium is independent of any 
pressure, having peculiar functions to perform according to the places 
where cerebral activity is called for. Donders, 11 Kussmaul and 
Tenner have trephined the skull of animals and have inserted in the 
holes watch glasses to cover exactly the exposed brain. In this way 
the variations of the circulatory system of the brain could be plainly 
seen, in some districts greatly increased, in others diminished. 
Furthermore, they could also prove the great interest which the cere- 
brospinal fluid has in the circulation of the brain. The cerebrospinal 
fluid, which is contained in a strong membrane running from the brain 
to the end of the spinal cord, is the regulator of the circulation, and it 
is supplied by the perivascular lymph vessels, which have an interest- 
ing part to perform. The way the veins are disposed is a protection 
to prevent venous congestion of the brain in the bodily efforts, and 
also for the arteries in the thyroid gland, which pressing against the 
branches of the carotids prevents an extraordinary flow of blood to 
rush towards the brain, leaving its circulation entirely independent. 

When a stimulus acts upon the receptive portion of the nerves, 
like a ray of light upon the retina, or a rough body upon the skin, etc., 
the effect of the stimulus is conveyed by the nerve to the nerve cell in 
the cerebral cortex. The cell is immediately affected by the impression 
received and propagates it to the neighboring cells of the same kind. 

11 Donders. " Ziemssen's Pathologie und Therapie Nervenkrankheiten " 
Band I. 



358 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The effect of the stimulus spreads like the wave circles produced in a 
pool of stagnant water by a falling object, which run in proportion to 
the intensity of its force. 

According to Mosso's experiments, it seems that when the effect of 
a stimulus reaches the cell in the cortex, the blood rushes to that 
area, increasing its nutrition. In this way the impression in the cells 
is changed into perception, and from their energy and activity it is 
transmitted in ideas or impulses. 

The cells, furthermore, have also the faculty of preserving not 
only an image, but also the strength and the character of the stimulus. 
In consequence the cells are able to remember the impressions. When 
a new stimulus reaches this cell, it rouses in it an image of a kind 
similar to that previously had, and this memory-image strengthens the 
new stimulus, consequently it produces a more distinct impression on 
consciousness. If the cell were unable to receive the impression from 
the second stimulus without remembering the first, it would be impaired 
in its interpretations. The stimuli then would be perceived, only with- 
out connection one with the other, and lacking the assistance of earlier 
impressions no knowledge could be obtained. This is the memory 
which is the most important faculty of a normal brain. 

To this must be referred the association of ideas, which is capable 
of giving us the complete image of the whole phenomenon. The senses 
are affected contemporaneously by the parts of the phenomenon, as in 
thunder we have light and sound affecting our senses. As a conse- 
quence, the sound by itself will be capable of recalling the light, and 
all together the whole phenomenon. In the same way the sound of 
falling water will recall a waterfall, the sea, etc. Wundt formulated 
the law that for the association of the ideas, four conditions are neces- 
sary: simultaneity, similarity, contrast and occurrence in the same 
place. 

In the organisms of the higher animals, the brain and the nervous 
system acquire knowledge of the external world, and this is used for 
the benefit of the individual. Memory makes this possible only by the 
association of the ideas. It is easily understood that a brain which is 
susceptible to a perception, and through the association of ideas to 
recall numerous representations, is far more able to recognize, con- 
ceive and judge, than another without association of ideas capable only 
of concepts derived from sense perceptions and of representations 
originated accidentally by contiguity. 

Although the association of ideas forms the most interesting part 
for the memory, yet there is no rule and no order in the representations 
without another mental faculty, attention. Attention brings the repre- 
sentations together in due order, as produced by the association of 



SYPHILIS IN RELATION TO DEGENERACY 359 

ideas, so that they may be used for knowledge and judgment. Atten- 
tion is the act of concentrating the mind on any object of sense, or on 
any mental conception. Ribot 12 defined it as a spontaneous or arti- 
ficial adaptation of the individual to a predominating thought. Hardly 
any faculty is more important for the intellectual progress of man 
than the power of attention, as maintained by Darwin. 13 It is a faculty 
which suppresses part of the images which have arisen from other 
excitations, and maintains the vividness of the others which are related 
to the causes exciting or to the object perceived. 

To obtain so important a result, we cannot fail to see that the 
blood vessels have an interesting part in the production of this psychical 
function. Nordau and Lehman 14 attribute this action to the interfer- 
ence of the will, which produces motor impulses to the muscles of the 
cerebral arteries. The arterioles are, therefore, contracted or dilated, 
and the supply of the blood is diminished or increased. The cells 
which receive a larger quantity of blood operate more powerfully, 
while the others, which have no supply, must suspend their action. 
The will only determines the attention, by the emergency, degree of 
clearness and duration of presentations. A strong will will much better 
adapt the organism for obtaining complete sense impressions, and 
induce memory images, capable of rectifying or completing a pres- 
entation. There is the adaptation of the whole organism to a pre- 
dominant idea, so as to give an exact knowledge of the different 
objects. This adaptation lasts as long as the cells acting in the pres- 
entation are capable of maintaining the attention, but when fatigued 
must cede the ground to other cells, and in consequence the adaptation 
is directed towards other purposes. In these intellectual functions the 
will is a very important factor, so much so that the stronger the will is, 
the better the organism is adapted to receive impressions, to connect 
them with memory-images so as to complete the presentation, and to 
suppress all other presentations which are outside of the subject. 

Attention is the result of culture capable of directing the powers 
of the organism, while a defective attention leads to errors and super- 
stitions. In order to obtain attention, a will power is required, which 
is only an attribute of a well-constituted and well-nourished brain. In 
individuals with malformed or exhausted brain will power is lacking, 
and as a consequence they are unable to give attention to any subject. 
An individual who is sick or weakened by disease is incapable of 
attention. 

The cerebral cortex receives the impressions not only from the 
nerves which are in relation with the external world, but also from 

12 Th. Ribot. "Psychologie de 1' Attention." Paris, 1889. 

13 " Descent of Man." 14 Quoted by Nordau. L. c. p. 84. 



360 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

the interior of the organism, from the nerves of the different organs 
and from the nerve centers of the spine and of the sympathetic system. 
Every stimulus is referred to the brain cells, where it causes a distinct 
presentation, which is related with the nerve centers from which it 
proceeds. So it happens that we feel the sensation of hunger and of 
thirst, which is aroused by the necessity of food or water in the organ- 
ism, and by the association of ideas, it recalls to us different articles 
of food or of drink. 

The nerve centers in some of the subjects under our consideration 
are morbidly affected on account of the circulation, or on account of 
morbid irritations, consequently they react in quite a different way 
from the normal ones. In some of the degenerates we find that every 
stimulus awakens sensual activity. Every presentation brings to them 
erotic thoughts, and they feel emotions of erotic nature at sights, words, 
odors, which they refer to unknown qualities. 

Indeed, syphilitic individuals are the most sensual class of people, 
and as already stated in syphilitic families we find remarkably numer- 
ous conceptions. In a syphilitic family we have found in seven years 
of marriage, first, one miscarriage in the fifth month of pregnancy. 
Four months after the lady was pregnant again and gave birth to a 
well child, which is living in good health. After this child, the lady 
had four miscarriages in succession, at intervals of a few months one 
from the other. Then she had twins, which were brought forth at 
maturity. Both were males, weak and sickly, and died in the fifth 
month of life, from inanition and eclampsia. After this she became 
pregnant again and has given birth to a male child, who is now seven 
months old, very pale and weak, suffering with colds (coryze) and so 
many troubles that the physicians are not able to understand the case. 
The lady now thinks she is pregnant again. 

In all syphilitic families which we have carefully followed, where 
the treatment has been neglected or been insufficient, we have remarked 
a large number of conceptions, of which some have resulted in abor- 
tions and others have brought to the world a syphilis-tainted child. 
We do not hesitate for a moment to refer the sexual supersensitiveness, 
the erotic perverted sensuality to syphilis or to syphilitic taint. Zola 
in his " Rugon Macquart," has well described Madame Gervaise and 
her daughter Nana, where he has shown that licentiousness and lewd- 
ness passes a miserable inheritance from the mother to the daughter. 
It is a constant law of nature that all living creatures resemble those 
who have produced them, and that from one generation to another, 
good and bad qualities of the body and of the mind are constantly 
transmitted. Syphilis is never mentioned, but a great deal of the 
psychical abnormalities are due to its poison or to its effects on the 



SYPHILIS IN RELATION TO DEGENERACY 361 

blood vessels. The inherited syphilitic poison is capable of exciting 
the nervous centers connected with the sexual activity, so as to make 
those affected belong to the class of degenerates or of the perverted. 

It is true that vice and crime are coeval with the human race, and 
that before the infection and propagation of syphilis there existed 
" good men," " bad men," " thieves," " murderers and prostitutes." 
The responsibility for vice and crime is usually thrown on the will 
of the individuals, without any consideration of the anatomo-patho- 
logical conditions of his nervous system. After the study of the 
alterations of the blood and lymph vessels induced by syphilis on the 
neurons, either preventing their development or diminishing their 
nutrition, it is apparent that it must have a great influence on the 
psychical functions of the tainted individual. 

Indeed, Lydston 15 is right when speaking of the fruitless results 
in the reform of delinquents by the penal system and by moral suasion, 
he finds the faults of both methods chiefly in the fact that their bodies 
have been forgotten. Man feels, thinks, wills and acts according to 
his anatomical conditions and the physiological development of his 
brain. This has always remained a conviction of the thinker, but on 
account of the scanty knowledge of the anatomo-physiological condi- 
tion of the brain, for centuries it has been only in the conscience of the 
scholars. 

After the institution of cranioscopy by Blumenbach, and after the 
anatomical studies supported by the philosophical ideas of Gall, the 
anatomy and physiology of the brain progressed to the highest point, 
through the works of Lauret, Gratiolet, Broca, Huscke, Virchow, 
Bischoff, Hown, Huxley, Lombroso, etc. 

The thesis, as already enunciated, was whether the remarkable 
class of men delinquents by nature do not exhibit facts to support and 
maintain that their criminal acts are the result of abnormalities in their 
brain. This class of delinquents already furnishes moral signs of their 
abnormal mental condition by the insufficiency of all means to prevent 
crime, and while they recognize the prepotence of society on them, 
yet they have no idea of injustice and follow their impulse to commit 
crime. Benedickt 16 in the examination of the brains and skulls of 
nineteen habitual delinquents, who died in the Croatian prisons, found 
defects of the whole cerebral mass consisting in a lack of development 
of the bridges of the gray matter, increased anfractuosities, a defect of 
early organic development. 

Betz, of Kieff, and Zernoff, of Moscow, who have made so 
many studies on the brains of the Slavs, have also recognized the 

15 Lydston, F. " The Diseases of Society." Philadelphia. 1004. p. 17. 

16 Benedickt, M. " Ueber den Gehirne der Verbrechern." Wien. 1879. 



362 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

atypical condition of the brains of the criminals. The atypical devia- 
tions of the brain of the delinquents places them in a special anthropo- 
logical variety. He must be in reference to his crime, as it were, a 
near relative of the epileptic or of the insane. Proclivity to commit 
crime is not the disease, but only the predisposition. Indeed, crimes are 
not to be compared with monomaniacs, but, in the case of an abnormal 
physical construction of the brain, are greatly the result of abnormal 
psychical conditions. This forms the predisposing cause ; social cir- 
cumstances, however, are the occasional factors. 

It is of great interest to establish whether the atypical conditions 
of the skull have any influence in the production of the anomalies of 
the brain. The superior portion of the skull is of the greatest impor- 
tance, as it contains the frontal lobes, which are the seat of the inhibi- 
tory or controlling faculties, which enable the man in the normal 
condition to exercise his will and resist animal impulses proceeding 
from other organs. The posterior lobe, abundantly covering the cere- 
bellum, is also very interesting for the intellectual development of the 
race. Consequently the highly developed occipital prominence cor- 
responding to the occipital convolution would be a sign of intelligence. 

The exaggerated curve of the parietal bones would very likely 
show a defective development of the central cerebral lobe, and this 
anomaly has been found in several delinquents and in epileptics. 

We cannot say anything definite in reference to the asymmetry 
and malformation of the cranial bones, but they may show a malde- 
velopment of certain portions of the brain, with perturbation of the 
functions originating in that area of the brain cells. 

We know a great deal about the relation of the affections of the 
special sensory and motor areas to the impairment or abolition of 
special senses or of the muscular groups, but we do not yet know 
the results of the affections of some areas of the brain cells in relation 
to certain psychoses. 

Nobody denies that moral perverts have an anomalous develop- 
ment or a disease of the sensory organs, but this is only recognized 
by faulty material development or dystrophies which can be seen ex- 
ternally. When in a man there are found signs of idiocy, micro- 
cephaly, hydrocephaly or some peculiar asymmetries in the construction 
of the head or of the face, it is immediately referred to a fault of brain 
development and his perverted moral condition finds easy explanation. 
There are, however, conditions of perverted functions of the brain 
which are occult and are not revealed by any external malformation. 

It is generally admitted that the form of the skull corresponds to 
the form of the brain which is adapted in it, as an organ of protection. 
It has also been established that the skull is moulded upon the brain. 



SYPHILIS IN RELATION TO DEGENERACY 363 

The regular closure of the sutures and of the f organelles in fetal life 
and after birth are of great importance in the development of the 
brain. Their regularity can be taken as a criterion to ascertain the 
degree of development and the integrity of the brain. 

The influence of syphilis on premature ossification of the fonta- 
nelles and on the union of the sutures is easily apparent. The skull 
of a healthy newborn infant shows a great predominance of the 
cranial over the facial portion. This is due to the undeveloped con- 
dition of the maxillary antrum and of the maxillae, and to the small 
size of the nasal fossae. The parietal and frontal eminence are large 
and conspicuous, the frontal sinuses and superciliary ridges are want- 
ing. The bones of the vault are without diploe, consisting of a single 
layer. The sutures are absent, each angle of the parietal bones being 
undeveloped is connected with fibrous tissues leaving a space called 
fontanelles. The anterior fontanelle is large, lozenge-shaped ; the pos- 
terior, small and triangular ; while the lateral ones are irregular in 
shape. 

This precarious union of the bones forming the skull of the 
infant lasts after birth for a certain period, then they become ossified, 
and the union of the bones is perfectly solid. The frontal fontanelle 
can still be felt open in the second year of life. It was called foks 
pulsatilis vertex palpitans, because the old physicians believed they 
were able to feel and to see the movements of the brain, from which 
the spirit of life was going through the nerves. The posterior fonta- 
nelle at the time of birth is already filled and after birth is soon 
obliterated. The same is true of the lateral fontanelles. This loose- 
ness of the bones forming the skull of the infant is to leave ample 
space for the development of the brain. Syphilis is the disease which 
directly influences a hasty ossification, and it is well known that before 
the third month of life the frontal fontanelle in a syphilitic child is 
solidly closed. This premature ossification and reunion of the bones 
must surely have an influence on the developing brain, which, com- 
pressed in its structure and not receiving the full quantity of blood, 
is somewhat impaired in its nutrition and therefore suffers in its 
evolution. 

We can see as active factors two different conditions influencing 
the developing brain of a tainted individual. One is the result of the 
toxic elements arising from the syphilitic germs, which produce an 
irritation in the nervous cells and are able to cause convulsions and 
spasms. Another lies in the anatomical changes in the blood vessels 
and in the bones. The bone canals, narrowed and distorted by an 
increased and too hasty an ossification, produce a pressure on the 
blood vessels whereby the circulation is impaired and the nutrition of 



364 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

the nervous cells becomes insufficient and the development of the 
organ imperfect and irregular. In many cases the premature closure 
of the fontanelles is the cause of microcephaly, which is accompanied 
by idiocy. 

Savage, Burr, Berkeley 17 and others do not lay much stress on 
syphilis as a producing agent of idiocy, for the reason that, in many 
cases of low grade idiocy there were not present the characteristic 
stigmata of the disease. In two years, however, he has seen only four 
cases in which there was an indubitable history of syphilis. The luetic 
poison, nevertheless, shows itself in many forms of nervous disease 
and is more frequently an indirect than a direct factor in the causation 
of idiocy, since it may not be until the third and fourth generation 
that the mental disability becomes prominent. With the respect due 
the opinion of so eminent a scientist as Berkeley, we must recall the 
fact that we have seen cases of idiocy in boys and girls who had 
inherited syphilis from their parents. 

The organs which are principally affected by the syphilitic process 
are the blood vessels, and as they nourish the nerve cells, their altera- 
tions are certainly responsible for an intellectual deficiency. An in- 
flammatory process affects the walls of the arteries, resulting in a 
diminution of their lumen which reduces the supply of nutrient fluid 
to a minimum. At the same time the same process affects the lymph 
vessels, narrows their channels and causes a hindrance to the lymph 
flow. This causes a partial edema of the brain substance, which 
results in epileptiform attacks. 

Syphilitic disease of the large vessels of the brain is so character- 
istic that it is easily distinguished from common arteriosclerosis and 
other degenerations. They show macroscopically loss of their trans- 
parency, become opaque and assume a grayish tint. Their lumen is 
found narrowed and hardened and in some cases it may be obliterated 
by the formation of a thrombus. 18 

Hiibner 19 microscopically demonstrated that the syphilitic proc- 
ess of the brain arteries consisted in a true specific inflammation. It 
may be considered a true endoarteritis, which is revealed by the pro- 
liferation of the endothelial cells, which on increasing forms, together 
with round cells from the nutrient vessels, a tissue of granulation 
similar to that of a gummatous production. According to the men- 
tioned author, this granulation tissue would run in the interior and 
alongside of the arteries, narrowing their caliber and completely in- 

17 Berkley, H. J. " A Treatise on Mental Diseases." 1900, p. 493. 

18 Ravogli, A. " On the Histo-Pathological Alterations of the Lymph and 
Blood Vessels in Syphilis." Cincinnati Lancet-Clinic, Oct. 17, 1903. 

19 Hiibner, O. " Die Luetische Erkrankungen der Hirn- Arterien." Leip- 
zig, 1874. 



SYPHILIS IN RELATION TO DEGENERACY 365 

volving the vessels. The process may stop after a permanent nar- 
rowing of the lumen or may continue till a complete obliteration is 
effected, leading the artery through degeneration to the condition of a 
fibrous cord, incapable of performing its functions. 

In some cases the adventitia as well as the intima show such a 
proliferation of cells as to be equivalent to a gummatous formation, 
reducing the lumen of the artery to a minimum. 

Indeed, Baumgarten 20 pointed out the condition of the adventitia 
in the affected arteries as the starting point of the process. He claims 
that, in the arteries of the cortex, the most frequent affection caused 
by syphilitic poison is a diffused periarteritis. The rapid multiplica- 
tion of the small cells among the fibrillar elements of the adventitia 
fill up the extravascular space, causing a heavy pressure. The media 
also infiltrated with the new cellular elements, suffers mostly from 
a process of necrosis, which causes the muscular elements to disappear 
and be replaced with a round-cell mass. This is also gradually reab- 
sorbed, leaving a mass of caseous degeneration with crystals of hema- 
toidin and debris. The intima is not indifferent to the syphilitic 
process. Cellular proliferation affects its layers and the lumen of the 
vessels is reduced in its caliber. 

Both processes described are clinically found as having disastrous 
effects on the cerebral substance. Berkeley refers to nine cases of 
dementia paralytica of specific origin, which at the autopsy showed 
the blood vessels affected with the described periangioitis. 

The proliferation, invading the adventitia, extends to the sur- 
rounding lymph space, which becomes filled with cellular and fibrous 
elements, which, on one side, enter into the media, and on the other 
permeate the surrounding nerve tissue causing degeneration of their 
connective structures. Alterations of the kind have been found, not 
only in specific troubles of the brain, but also in cases of interstitial 
degeneration, as in the disease of the pyramidal tracts, tabes dorsalis. 

After the brief description of the pathological alterations produced 
by syphilis on the vessels of the nervous system, it is easily understood 
that this is one of the most effective factors of diseases of those organs. 
Syphilis transmitted in a hereditary way to the fetus will have the 
same influence on the developing vessels and will consequently be the 
cause of congenital faults, or of deficiency. Anatomical abnormalities 
have been found in the construction of the basilar arteries, which are 
significant of a defective formation of the whole body. In some cases 
there has been found an absence of the large basal arteries or an un- 
usual caliber in them. The noted absence of the right or left posterior 
communicating artery must have great influence on the development of 
20 Baumgarten. Vir chow's Archiv, 1878- 1879. 



366 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

the brain ; and when the entire system of the basal vessels is too small, 
it will fail to bring a sufficient blood supply to the encephalon. The 
cerebellar arteries arising from the basilar artery have in many cases 
been found too small. So far statistics on this subject are lacking 
and as a result we cannot give any definite data. The alterations 
already mentioned are sufficient to show that syphilis is one of the 
most important causes in the production of psychoses. 

In syphilis, therefore, we find an element of causation capable of 
leading to physical and moral degeneracy. Its poison, subtle and dif- 
fusive, reaches the most remote cells of the body, producing irritation 
or impairing their nutrition. This will prepare on the one hand a 
quantity of idiots, of epileptics, of imbeciles, and on the other a class 
of persons mentally deficient or of extravagant tendencies, of de- 
generates. 

In our views we do not oppose the therapeutics used by the 
penologists to try to reform their man, to elevate him, and in case of 
failure to put him in jail or administer capital punishment. We do not 
argue against the efforts to make of a criminal a man with a healthy 
and sound brain. We find, however, that one of the most important 
remedies rests with society in general ; to try to diminish every possible 
cause capable of deteriorating the nervous system and the mental 
faculties of the individual. 

PHYSICAL SIGNS OF DEGENERACY 

The deformities, dystrophies, abnormal types, which we have 
noted as results of syphilis in the third generation, in the so-called 
heredo-syphilitics, are those which constitute the stigmata of degenera- 
tion. For this reason we have grouped them together to show the 
influence of hereditary syphilis in the production of degeneration. 

Degeneration which is the result of syphilis in the third generation 
is not of a permanent character in the succession of generations. In 
the lowest grade of degenerates the abnormal development remains in 
the individual and dies with him. In these cases there is no reproduc- 
tion. In the highest class of degenerates the promiscuity of the races 
in the marriage, is a great correcting element in the health of the 
generations. The abnormal development is lost and children are born 
without marks which were visible in the father. 

Micro cephalus. — Smallness of the cranium is the result of an 
imperfect development of the brain, as porencephalus, cerebral hemor- 
rhage in infancy, rudimentary evolution of the cortex and corpus 
callosum, are from the too early closure of the principal sutures. 

The microcephalic skull may represent either the brachicephalic 
or the dolichocephalic type, but it is remarkably small. I" a case 



SYPHILIS IN RELATION TO DEGENERACY 367 

referred to by Berkeley, 21 a man six feet and two inches in height had 
a skull circumference of forty-four centimeters, and the brain weighed 
only 400 grammes. The bones and muscles were fairly developed, 
but the intellect had never progressed beyond the capacity of using 
coherently a few words. In cases of microcephalus below forty-four 
centimeters, there is a stunted growth, and an arrest of the higher 
cerebral functions. 

The crania of microcephalics may present deformities, but they 
usually are symmetrical, but always showing the tendency to inferior 
mental capacity. 

Macrocephalus is usually due to hydrocephalus in early life, rarely 
to hyperplasy of the cerebral substance, or to the thickening of the 
bones. The skull is more symmetrical than that of the microcephalic, 
as the overgrowth has been equal in all directions. The facial bones, 
in contrast with the overdeveloped cranium, seem too small and dis- 
proportionate to the size of the head. The inferior and superior 
maxilla are smaller than in the normal size. The individuals of this 
unfortunate class are nearly all dwarfs, show signs of having suffered 
rickets, distortion of the long bones. Their skull is usually of the 
brachycephalic type. 

The too early closure of the cranial sutures is responsible for the 
deformities and asymmetries of different types. The synostosis of 
the coronal suture and of the posterior portion of the interparietal 
suture will cause an upward projection of the skull forming the so- 
called tower head or pointed head. Amongst idiots and imbeciles 
there is to be noted the great height of the head disproportionate to 
the other measurements. The unusual shortening of the anterior re- 
gions causes the protrusion of the eyes, giving them a flat appearance. 

The premature closure of the frontal suture is the cause of a 
narrow forehead, with a compensatory broadening of the posterior 
regions of the skull, which gives to the head a kind of triangular 
appearance. This type of skull is called trigonocephalic, represents 
closely the fetal skull, and is peculiar to all classes of imbeciles. It 
belongs to the dolichocephalic type. 

The early unilateral synostosis of one frontal with the corre- 
sponding parietal bone is the cause of the projection of one-half of the 
head, inducing obliquity of the cranium, which is called plagiocephalus. 

On account of impaired development of the parietal bones the 
cranium remains flat, platycephalus, an anomaly which is often found 
among epileptics and hereditary degenerates. A compensatory devel- 
opment of the basal regions takes place causing the broadening of 
all diameters in the horizontal measurements. 
21 Berkeley. L. c, p. 536. 



368 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

When the interparietal suture is closed too early the head takes 
on a peculiar elongated shape like two craniums ; it is an exaggeration 
of the dolichocephalic type, and it is called scaphocephalus. 

The frontal region may be pushed forward, with a projection 
of the brows and an increased depth of the eye-sockets. The occiput, 
however, may be projecting without deformity of the forehead as the 
result of an early closure of the posterior half of the sagittal suture. 
In this case the deformity consists in an attempted compensation from 
the lambdoidal suture, producing an abnormally protuberant occipital 
bone. This gives an accentuated dolichocephalic appearance to the 
skull. 

When at an early age synostosis occurs between the occipital and 
temporo-sphenoidal sutures, it induces abnormality of the sphenoidal 
bones, as it is found in many cases of cretinism. 

Other minor anomalies in the shape of the skull, consisting of 
peculiar asymmetries, are found according to Peli, 22 to the extent of 
only 12.50 per cent, in normal individuals, and 42.7 per cent, in the 
insane. While in hereditarily burdened persons of both sexes, ab- 
normalities of the skull are found at the rate of 64.3 per cent., and in 
men alone belonging to this class the proportion reaches as high as 
88.5 per cent. The auricula present innumerable variations from the 
normal type. The fusion of the lobulus together with the skin of the 
neck is so often found in sane individuals, that it can scarcely be 
considered as a stigma of degeneracy. Vicious implantations of the 
ears, ears projecting too far, or too closely implanted on the head, 
ears inserted at abnormal angles, or implanted too high or too low 
upon the neck may be considered as brands of degeneracy. The form 
of the ear shows anomalies and deformities which make them rank 
with the other marks of degeneracy. In some cases the ear has no 
lobules, or there is unusual prominence of the antihelix, or an excessive 
length of the organ with distortion of the helix, antihelix and anti- 
tragus. To this class belong the Darwinian ear, w T hich has the helix 
interrupted by a tubercle where its transverse passes into the descend- 
ing portion ; the ear of Morel, in which the normal folds are obliterated 
and the whole auricula appears much larger, projecting outward from 
the sides of the head like the handles of a pot. 

The nose shows a peculiar shape, as that of a saddle ; the root 
of the organ is deep underneath the glabella, and has a nearly hori- 
zontal direction. The nostrils are larger than in the normal. The 
septum is often deformed. The broadness of the nasal bones is 
usually found in cretinismus. 

22 Peli. " Cefalometria in 670 alienati." Arch. Hal. per le mal. nervose, etc. 



SYPHILIS IN RELATION TO DEGENERACY 369 

In treating of syphilis in the third generation we have already 
pointed out some irregular pigmentations of the iris, which are the 
result of specific taint. We can add in this connection congenital 
strabismus, coloboma, cloudy cornea, pigmentary retinitis, total con- 
genital blindness and congenital ptosis. Nobody would doubt for a 
moment the luetic origin of these deformities. 

In cases of idiocy and imbecility the long bones are found of an 
abnormal development, and tending to dwarfism. The bones are ab- 
normally broad in cretinism. Quite often there is found congenital 
club-foot, club-hand, distorted and supernumerary digits, or only two 
or three fingers, as shown in one of our cases. These are considered 
stigmata of degeneration, but we should rather say stigmata of in- 
herited syphilis. 

The mouth shows decided marks of degeneration. The orifice 
may be too large or too small ; in some cases it shows hare-lip or cleft 
palate, signs of inherited syphilis in the third generation. The soft 
palate shows some anomalies, being too long, or irregular, with an 
abnormal uvula. The most important abnormalities are found in refer- 
ence to the alveolar processes, which at times are too narrow, at times 
too broad, retaining teeth of the first dentition. The hard palate shows 
signs of malformations, which according to Berkeley are found in 
nearly forty per cent, of all degenerates, with peculiar types of 
deformity. 

A normal palate shows a segment of a low arch with its highest 
point on the palatine apophysis of the superior maxillary bone, and 
its pillars in the alveolar processes. This normal type finds a great 
many variations ; in some the palate is flat, in others normal with a 
V-shaped incision in the line of the central suture. In some others the 
arch is very small and elevated on its upper segment. Recently at- 
tention has been called to a ridged and rough formation of the central 
suture, which in some give the sensation of bony elevations, which 
form the abnormality known as torus palatinus. Ferrari, in 1121 skulls 
of insane persons, found it present in fifty-two per cent. Nacke found 
it in 32.9 per cent, of insane women. It is also found in sound persons, 
but not so frequently as amongst the insane. 

We must mention that Prof. Baccelli in his lectures taught and 
maintained that one of the unmistakable signs of old acquired syphilis, 
and mostly of inherited syphilis, was this condition of exostoses along 
the side of the central suture of the palate. In our experience we have 
often had occasion to use this sign to establish the presence of an old 
latent, or at least of an old extinct lues, or of an inherited taint. 

The deformities of the palate referred to are in no way dependent 
on cranial construction. Berkeley would scarcely comprehend this 



370 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

condition of ridged suture of the palate among the deformities which 
are present in insane and in degenerate individuals. It is not our aim 
to treat profoundly this question which interests so much the phrenolo- 
gist, we only want to point out the fact that the so-called stigmata 
of degeneracy consist in malformations or deformities, which in many 
instances are to be attributed to inherited lues. 

We have already mentioned the defectively developed and the 
supernumerary teeth, their irregular implantation, the imperfect de- 
velopment of the alveolar process, and the irregular shape called notchy 
teeth. 

The genitals are frequently found abnormal amongst degenerates, 
and abnormal development in these organs has been already pointed 
out as a result of inherited lues in the third generation. In degenerate 
women the infantile uterus is quite frequent. In men hermaphrodit- 
ism is a stigma of degeneration, but there are deformities of minor 
importance, as hypospadias, defects of the prepuce, nondescent or 
rudimentary development of the testicles. In the general development 
of the body we have already had occasion to mention the infantilism 
and dwarfism, which we have considered as the result of syphilis in 
the third generation. 

We do not want to be accused of considering all degenerates as 
heredo-syphilitics, but we must say that the degenerates are frequently 
tainted individuals in the third generation. In the same way we do 
not maintain that all tainted individuals belong to the degenerates. 
In our practice we see every day boys and girls whose parents we 
have treated for syphilis, and even some of them we have treated in 
their infancy for inherited lues, go to school and obtain honors above 
their classmates. They show bright intelligence, quick perception, 
sound memory, and do not betray so far any trace of mental deficiency. 
Syphilis does not always produce degenerates, nor are all degenerates 
heredo-syphilitics, but without doubt luetic taint has an influence in 
the production of degeneration, and vice versa, a great many of the 
degenerates may recognize lues as the principal cause "of their defective 
mental development. In this way only do we understand lues as the 
cause of degeneration. 

SYPHILIS AND THE DECADENCE OF POPULATIONS 

In order that we may have an idea as to whether syphilis may 
be considered a cause of decadency of populations, or at least of a 
period in their history, it is necessary to briefly consider the first ap- 
pearance of this disease. Fra Castorius gave the poetical name of 
syphilis to the loathsome disease, which, it is related, was brought to 
Europe at the end of the fifteenth century and epidemically spread 



SYPHILIS IN RELATION TO DEGENERACY 



371 



over every country. Before this it received the name of the country 
from which it was believed to have come as a rebuke to the carriers, 
as morbus gallicus, mat de Naple, Spanische Pocken. Fallopius made 
the Spaniards responsible for the introduction of the scourge into 
Italy, and Leo Africanus claimed that the spreading of the disease 
was caused by the Marrans, chased from Spain by Ferdinand the 
Catholic. Writers, contemporaries of Columbus, maintained that the 
crew of his ships returning from West India carried the scourge to 
the Spanish and Portuguese ports, and from there it spread all over 
Europe. 

In fact, Columbus returning from his first voyage stopped first at 
Lisbon, then at Palos, before going to Seville, and thence, with many 
of his companions, he went by land to Barcelona to meet the King 
and the Queen in order to give them the report of his magnificent 
success. Barcelona, as Rodrigo Diaz, physician and historian stated, 
was soon affected by the new disease, and it made frightful progress 
there. 

In 1494 Don Pedro de Margarit was on his way back from his 
voyage, and in his ship everyone was infected with syphilis, not 
excepting the chaplain, a Benedictine friar, who was in a worse con- 
dition than the sailors. 

In 1496 Columbus, chained and handcuffed, landed in Cadiz, and 
it is related that 200 of the crew of that ship were infected with 
syphilis. 

The fact of the importation of syphilis from America was bitterly 
disputed by Diaz de Isla, Oviedo, Hernando Colon, the natural son 
of Columbus, and later on by Astruc, Swediaur, Girtanner and many 
others. But in spite of their efforts, there cannot be found in antiquity 
any description of a disease which can be identified with syphilis, such 
as the one we find in 1496, according to Aloysius Luisinus and after- 
ward according to Fracastorius. The progress of the disease at that 
time can be traced geographically from one country to another and 
even from one city to another. 

From Spain the new scourge was carried to Naples by the soldiery 
sent there to oppose Charles VIII, and from Naples it invaded the 
whole of Italy. So it was that from 1494 to 1498 nearly every Italian 
city and afterwards all the countries of Europe were infected, spread- 
ing the scourge all over the world. The disease was so serious and 
so severe for many years, according to F. Guicciardini quoted by 
Tommasoli, as to cause the fear that it would be transmitted to pos- 
terity as a dire calamity. 23 

23 Tommasoli, P. " La sifilide e la decadenza del secolo XVII." Fest- 
schrift fiir Professor Neumann, 1900. 



372 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The disease did not remain limited to the lower classes of society, 
but also affected very prominent men in the highest ranks of life. 
Everybody knows that Henry VIII, King of England, had sentenced 
to death Cardinal Wolsey on the principal accusation of having 
spoken too near to his ear, w T hich was believed to be one of the 
ways of transmission of the French scourge. The noble d'Aubigny, 
commanding the troops of Charles VIII, was taken back to Florence 
and to Bologna in a kind of basket because he could not move himself 
on account of the ugly disease. 

If we want to have an idea of the spreading of the disease among 
the people w 7 e must refer to the writings of Luca Landucci, who stated 
that the new scourge made its appearance in Florence in June, 1496, 
and one month afterward the city was filled with diseased people. 
In December the disease had spread to the surroundings, and every 
city had to suffer its ravages. In Venice the disease had spread among 
the inhabitants so severely that in 1494 some Venetian galleys sta- 
tioned in Corfu were unable to leave on account of the fact that the 
men of the crews were nearly all infected and unable to work. 

Syphilis spread among all classes of society and even religious 
people were not excepted. In Tuscany, in 1505, the priests not yet 
infected demanded the privilege of having their communion service 
locked so as to prevent infection through it. In the Archives of the 
Sanctuary in Todi there was a register of the miraculous recovery of 
priests and nuns from the French malady. 

In the same way, professional people, writers, artists, etc., were 
not spared by the scourge. Benvenuto Cellini, according to his own 
testimony, could not finish a magnificent work in gold which had 
been ordered of him by Pope Clemens VII, on account of a terrible 
disease of the eyes which prevented him from seeing. He says : " The 
infirmity which I had, I believe to have been acquired from that pretty 
woman who was in my house at the time when my store was burglar- 
ized. That disease took nearly four months to show 7 its presence, and 
then appeared all at once. I was covered with a kind of red vesicles, 
the size of a cent. The physicians did not want to give it the name 
of the French malady, but I knew the cause, and I knew what it was." 

The disease in its spread did not find any barrier of rank in 
society, or of distance of sea, but like a conflagration invaded every 
country and all castes of society. 

According to Okamura and Tokujiro Suzuki, 24 it seems that 
syphilis was introduced into China and Japan in 1504, by the Portu- 

24 Tokujiro Suzuki. " Ueber Syphilis in Altertum speciell in China und 
Japan." Inaug. Dissert. Rostock, 1903. Ref. Monatsh. f. prakt. Derm. Bd. 
38, p. 487- 



SYPHILIS IN RELATION TO DEGENERACY 373 

guese sailors. Before the time of Columbus no idea can be obtained 
of the existence of this disease in Asia. Fujikawa, 25 quoting from 
the Hoii-i-shuo, states that towards the end of the Kodi period there 
spread among the people a severe eruption, which was imported by 
the Cantonese, and in the Northern parts of China it was not known, 
and for this reason it was called the Canton eruption. He believes 
that the scourge invaded China about 1505 or somewhat later, after 
the landing of the Portuguese in India and Goa, with which the in- 
habitants of Southern China had great commercial intercourse. From 
China the scourge passed easily into Japan. In the beginning the 
disease was considered in China as one of miasmatic origin, but in 
1580 it was recognized to be the result of impure sexual intercourse. 

According to Okamura, there cannot be found any mention of 
this disease in the old Japanese books, and only in the fifteenth century 
did this disease become known. In 1575 lues was described in Japan, 
and it seems that in 1569 the disease was imported to Nagasaki by 
the Portuguese and the Chinese. The Japanese have learned the 
peculiarities of lues from the Chinese physicians, and they held that 
chancre, bubo, exanthema were produced by the same poison. 

Our point is to show that syphilis was not a disease known in 
the China and Japan of antiquity, but was only known at about the 
time it made its appearance in Europe. The arguments which have 
been used by the distinguished writers to maintain that syphilis was 
known to the 'old Jews, to the Greeks and to the old Romans, are not 
so convincing as the plain history of the epidemic onset of syphilis 
amongst the European populations. Indeed, if syphilis had existed 
amongst the Greeks and the old Romans, it seems an impossibility 
that it should have escaped the attention of medical men, such as 
Hippocrates, Galenus and others, who have given the most accurate 
description of diseases known in their days. 

The study of the human bones which were found in old graves, 
especially in the Indian mounds in America, have revealed deformities 
and alterations which have been considered by observers as pointing 
to syphilitic origin. Many of them have so referred the existence of 
syphilis to a prehistoric age. Others, however, have denied syphilis 
to be the cause of those alterations and have maintained that it could 
also have been the result of other diseases. Some interesting illustra- 
tions of deformed bones of old inhabitants of America have been 
given by James N. Hyde, 26 and the increased thickness, abnormal 



25 



Fujikawa, Y. " Ueber den Ursprung der Syphilis in Ostasien." Japan. 
Zeitsch. Bd. ii, p. 346. Ref. Monatsh. f. frakt. Derm. Bd. 38, 1904. 

26 Hyde, J. N. "History, Geographical distr.," etc. A System of Gen. Urin., 
etc. Morrow, 1893. 



374 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

curvature, the appearance of exostoses, all point towards the possi- 
bility of syphilitic bones. 

Neumann 27 referred to the studies of Seler, who found in the 
old Mexican literature collected by Las Capas, that in old Mexico 
syphilis was known under the name of " nanauall " and that they had 
their means of treatment. He studied, moreover, anthropomorphic 
vases from Peru at the time of the Incas, and the figures often show 
a loss of the nose and alterations of the limbs. Although these de- 
formities could have come from inflicted punishment, yet Neumann, 
together with Polakowsky, Heger and others, concluded them to be 
nothing else than lesions resulting from tertiary lues. 

If we try to go to any depth in this subject we shall find abundant 
proofs of the knowledge of venereal sores of a contagious nature 
amongst the Romans and the Greeks, but there is no indication of the 
consequent phenomena, pointing towards syphilitic infection. 

After the return of the sailors of Columbus from the West Indies, 
in March, 1493, the disease was clearly known in an epidemic form, 
invading successively every country of Europe. This leaves but little 
doubt on the origin and on the importation of the disease. 

In the first part of our book we have seen and we have often 
repeated, that syphilis or its toxins have a great influence on the 
psychical functions. We have seen a great series of nervous affections 
result from syphilis, and the existence of syphilitic insanity and syph- 
ilitic dementia is to-day an established fact. 

It is more than natural that at the time when the disease was not 
known and no idea of rational treatment could be administered, affec- 
tions of the nervous system were much more frequent. Indeed, the 
fear of the epidemic, the lack of confidence in the physicians, and the 
impossibility of being cured, must have driven a great many to des- 
peration. Nicholas Leonicene, who described in 1497 the new epidemic, 
spoke of certain vapors which went to the brain as a result of the new 
disease, and on account of which the sufferers went to drown them- 
selves in rivers and wells. 

This dispirited mental condition which is often induced by the 
syphilitic poisoning, so well described by the old physicians was after- 
while overlooked and nearly forgotten. W r e must come to our times 
to find Fournier, Murri, Mairet. Tommasoli and others, who have 
called attention to the frequency of the cerebral affections arising 
from syphilis. Moreover, they have shown that syphilis induced mental 
disturbances, which are produced not only in the man primarily 
infected, but in his children and grandchildren may be shown psychical 
derangements from hereditary luetic taint. 

27 Neumann, I. V Internat. Dermatologen Kongress. II Bd., 1905, p. 64. 



SYPHILIS IN RELATION TO DEGENERACY 375 

We must state that after so many years the disease has somewhat 
changed in its virulence. It has been demonstrated that the modern 
ways of administering the remedy has greatly attenuated the virulence 
of the disease. Indeed, cases of malignant syphilis which frequently 
occurred twenty-five or thirty years ago are only rarely seen to-day. 
In those times, when nothing w T as known of the disease and nothing 
was known about the treatment, it was at the height of its virulence. 
From the historical records we find that the predominating symptoms 
were vapors affecting the brain, in many, dolores osteocopi in a great 
many, gummata and nodes in nearly all the sufferers. 

This report gives us reason to congratulate ourselves for the 
result which we have obtained in the management of the disease, which 
surely has been diminished in its intensity, and the ravages of the 
tertiary lesions have been in so great a measure controlled and avoided. 

It has been alleged that the frequency of the nervous diseases in 
our times is due to the excitement in life, accompanied by the modern 
appliances, the volume of business, and the necessity of being con- 
tinuously in a rush. Nordau so explains the so-called fin-de-siecle 
affection, and the supposed increase of degeneracy and of hysteria in 
our generation. 

At those times there were no railroads, no steamships, no compe- 
tition, he claims that life went on quietly and smoothly, as in the times 
of the ancient patriarchs. Nordau refers to the great difference be- 
tween the life of those blessed times and the life of to-day, in recount- 
ing the trip of the famous naturalist, Hoffman, who in 1822, in order 
to go from Bremen to Leipzig, took four days and four nights. He 
reached Leipzig in the night and could not find a restaurant open. 
He groped about the streets to find the door of the hotel, and was 
obliged to hurt his fingers striking the fire stone to light a tallow 
candle, so as to be able to find his bed. 

Compare this trip with a trip in our days. If Hoffman had had 
a railroad train, which in a few hours would have carried him from 
Bremen to Leipzig, if he had found the hotel 'bus at the depot, a bell 
boy to take him to his room, who by turning the switch would 
have given plenty of light to the room, he surely would have saved 
a great deal of strength, much discomfort and worry. It is. therefore. 
only nonsense to attribute so much nervous irritation, so much loss of 
nervous power, to the railroads and to other features of modern life 
which have made existence more comfortable and more pleasant than 
it has ever been before. 

If we follow Tommasoli in the consideration of the peculiar 
social circumstances at the time when syphilis made its appearance as 
an epidemic, we find that the conditions of mind of the populations were 



376 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

not so quiet or so tranquil as is believed. On the contrary, it was just 
after the time when there occurred in England the death of Edward 
IV, an ambitious and licentious king, who was continuously planning 
to get rid of anyone who was in his way. He had his brother Clarence 
charged with treason and sentenced to death, giving him the privilege 
of choosing the method of execution, which was that of being drowned 
in a butt of malmsey. Prince Edward, his eldest son, a boy of thirteen, 
succeeded him, who, while he was going to London, was taken by the 
Duke of Gloucester and deprived of his tutors and friends. He was 
compelled by Gloucester to ride before him bareheaded, while he 
(Gloucester) was pointing him out to the populace with the order, 
" salute the king." Gloucester was appointed protector of the king- 
dom, and just at the moment when the Council was in session at 
Westminster, he sent a body of armed men to burst into the assembly, 
who with the cry of " treason," seized upon those members who were 
supposed to be inimical to the Duke. Among the members who were 
carried off and thrust into the Tower were the Archbishop of York, 
the Bishop of Ely, and Lord Stanley, the most prominent men of the 
kingdom. Lord Hastings, another suspected party, was soon con- 
demned to death and beheaded. 

It was at that time that Sir Thomas Ratcliffe with a large body 
of followers entered at Pontefract and put Rivers and Grey to death. 
The same hunchback, Gloucester, compelled the Archbishop of Can- 
terbury to give into his power the two York princes, whom he de- 
clared bastards, claiming that the marriage of King Edward IV with 
Elizabeth was bigamous, because he had secretly married another 
woman. He could not endure that the English throne should be filled 
by the spurious brat of his brother Edward, and he substituted his 
coronation to that of his nephew Edward, taking the title of Richard 
III. 

He got rid of the two innocent Yorks, both of whom were found 
suffocated in their bed by hired murderers. This hyena seated on 
the throne of William the Conqueror cut down anyone who was in 
his way, and in his hypocrisy never knew pity, love or fear. 

When Richard III scented the conspiracy of the duke of Buck- 
ingham, he had him beheaded immediately, and all his followers put 
to death. 

Henry of Richmond, with a little army helped by the desertion 
of some of Richard's soldiers, engaged in battle with him at the Abbey 
of Merivalle, near Bosworth Field, and punished the traitor by killing 
him. It was near the end of the same century when Henry assumed 
the crown of England as Henry VII. Under his reign came back 
all the horrors of the Norman invasion. At his time the Wars of the 



SYPHILIS IN RELATION TO DEGENERACY 377 

Roses destroyed the feudal nobility of England, but the political dis- 
cord kept on and cost England nearly one and one-half million victims. 

Looking at this historical report, it seems that at the time of the 
epidemic invasion of syphilis, the minds of our English brethren were 
not so tranquil and so quiet as we might have thought. 

In Spain the nervous system of the inhabitants was also somewhat 
excited by the political secession. King Henry IV, incapable of 
reigning, the queen of not exemplary life, the ministers corrupt, the 
nobility seditious, the clergy greedy, the poor people oppressed and 
vexed, this was the condition of the times. Just at this point the 
civil war began between the two women, Juana and Isabella, the 
latter gaining the victory. Through the marriage of Isabella to 
Ferdinand the Catholic, Aragon and Castile were united into one 
kingdom. 

Under Ferdinand, the bigot king, the dreaded Inquisition ac- 
complished its purpose as a powerful institution. The Moors were 
chased from Spain, and the Jews were persecuted and then expelled. 
The most iniquitous persecution of the inoffensive children of Israel 
took place, who were driven out of their homes and turned naked 
into any part of the world into which they could make their way. 

At this time the Genoese adventurer, Columbus, succeeded through 
the munificence of the Queen in obtaining ships, and men, and found 
a new world beyond the Western ocean. 

In France Louis XI followed the same lines by keeping the 
French people in an excited condition of mind. He, a parricide and 
a fratricide, frenzied by the terror of death, spent his life in a voluntary 
jail, surrounded by bodyguards, monks, and friars, mixing the most 
ridiculous superstition with the most merciless cruelty. An execrable 
being, despised by everyone, he died of starvation for fear of being 
poisoned by Charles VIII, his own son. Charles assumed the throne 
at fourteen, and was an analphabet. 

In Italy at this time things were not much better; every town, 
city or community was alone, independent as municipal governments. 
It was just the beginning of the Dark Ages, and political unity had been 
destroyed. These small towns or municipalities kept on in jealous 
rivalry with each other, struggling for supremacy. It was a period 
when the morality of the people of a great part of Italy was at a 
hopeless ebb. It was an epoch of rapine and lawlessness. Property 
and life received no adequate protection from society. The country 
was infested with robbers and brigands, who preyed with reckless 
audacity on whatever industry had stored in hamlet, town or castle. 
Hired ruffians prowled about every place and used their stilettos under 
the direction and protection of their powerful masters. In Rome we 



378 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

find Rodrigo Borgia pope under the name of Alexander VI, who on 
account of his treacheries, murders and robberies, was deposed and 
expelled from the papal states by Julius II. 

The close of the fifteenth century and beginning of the sixteenth 
are noted in the history of Italy for the invasion of the country by 
the armies of Charles VIII and Louis XII of France. 

Milan, which had seen Galeazzo Sforza assassinated at the door 
of a church in punishment of his crimes and cruelties, was under the 
domination of Ludovico Sforza, who was captured by Louis XII, and 
sent to prison in France. Two countries had seized Italy, the northern 
part was occupied by the armies of Louis XII, and the southern and- 
central parts by the armies of Ferdinand of Aragon. Louis XII then 
entered in collusion with Ferdinand of Aragon to divide the kingdom 
of Naples between them. Soon, however, they quarreled over the 
spoils and the French were defeated in the battle of Seminara by the 
famous Gonsalvo de Cordova, a general of Ferdinand of Aragon. 
Louis was then expelled from Southern Italy. 

In Venice the people, merchants by natural inclination, were at 
a high pitch of excitement on account of the discovery of Vasco di 
Gama. They feared that the new discovery would ruin their entire 
commerce. In 1507, Louis, after having defeated Genoa, formed with 
Emperor Maximilian, Ferdinand of Aragon and Pope Julius II, the 
celebrated league of Cambrai with the view of the destruction of the 
Republic of Venice. 

In Florence, the beautiful city, the cradle of the sciences and of the 
arts, the political conditions were by no means any better. The 
republic was divided into small parties, and Fr. Savonarola, the elected 
of the people, was striving to institute radical reforms of government. 
The Medici were expelled from the government and Savonarola was 
the most ardent republican. Pope Alexander VI., who made common 
cause with Medici, began the persecution against Savonarola. One 
night he was taken from his convent with two of his companions, and 
all were killed and then burned in a public square as heretics. 

We can see that the peoples were not in a very quiet and peaceful 
frame of mind when the syphilitic epidemic began to invade these 
countries. At the same time in the midst of their chaotic political con- 
ditions, of their civil dissensions, of their fratricidal wars, they began 
to see the ravages of this new disease, which filled them with terror 
and despair. 

The political dissensions, the wars, the persecutions, were not 
enough, but in 1522, just after the election of Pope Clement VII., the 
bubonic plague invaded Rome, killing 18,000 inhabitants. In 1524 the 
same plague attacked Milan, where over 50,000 people died in less than 
four months. 



SYPHILIS IN RELATION TO DEGENERACY 379 

If we compare the century before the introduction of syphilis in 
Italy with the following century, we find it strange that in the midst 
of feuds, in the midst of the horrors of starvation and pestilence, litera- 
ture, science and art were flourishing. Boccaccio with his fantastic 
spirit wrote his stories of the Decameron. It was an era of poets, of 
artists of immortal fame. Michelangelo, Raphael, Cellini, were giv- 
ing to the world the most beautiful and divine artistic works. They 
were obliged to work with the sword constantly near them, and an 
artist ought to be a soldier also, in order to defend his life, threatened 
at every moment by the continuous factions. It was at that time that 
the celebrated Italian statesman, Nicolo Macchiavelli in Florence, the 
father of the diplomatists, was the chancellor of the government. With 
all his diplomacy, however, he did not escape the rage of Cardinal de 
Medici and of Pope Leo X., who had him deprived of his office and 
tortured under the accusation of conspiracy. 

A few years later an era of magnificent scientific and literary pro- 
ductions was opened in England at the time of Elizabeth. It was an 
outburst of intellectual activity, when the English mind felt the joy of 
emancipation. From Sir Thomas Moore with his " Utopia," Sir 
Thomas Wyatt, William Dunbar, Thomas Sackville, Lord Buckhurst, 
to Edmund Spenser with his " Belle Phoebe," was a magnificent epoch 
of poetical geniuses. This epoch was crowned by the giant and por- 
tentous mind of Shakespeare, who was the personified spirit of his time. 

Amongst physicians in the first part of the sixteenth century we 
find in Italy Mondino, Berengario da Carpi, Vesalius, BenedettL 
Benivieni, who made interesting discoveries in human anatomy. Nor 
must we fail to mention Philip Ingrassias of Naples, Constant Varoli, 
from whom some organs of the central nervous system have derived 
their names, Michel Servet, who described the circulation of the lungs 
and was then burned at the stake, Fabricius de Aquapendente, who 
studied the veins and described the valves, William Harvey, who clearh 
explained the circulation of the blood, which he had learned in Padua 
under his teacher, Eustachius Rudio. 

Gradually, as the generations of heredo-syphilitics were piling up 
in the world, science, art and literature began to lose ground. The 
interest was all concentrated in fantastic poetry of a religious nature, 
which was followed by the Protestant revolutions of Luther, Zwingle 
and Calvin. This prompted Adrian VI. to impose a gloomy Lent, 
which made sad all good livers of Italy and* of other countries. 

The studies of medicine, which had been g'airiing in the golden 
time, began to lose ground and ignorance began to give place to the 
most absurd superstition. 

Pest, syphilis and contagious diseases in general, were considered 



380 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

as a result of the will of God. Paracelsus, who yet represented a 
learned physician of his time, stated that any contagious disease came 
from the planets, particularly from Saturnus, who devoured children. 
In the seventeenth century in Rome, 28 we find employed against leprosy, 
syphilis and other diseases of the skin the following treatment : " After 
the patient has been regularly purged, he was introduced into a Grotto 
near Bracciano, which was inhabited by innumerable snakes. The 
temperature of the Grotto was very warm and soon produced abundant 
perspiration, and the patient, who had taken a hypnotic potion, soon 
fell asleep. He was entirely naked, and the reptiles, attracted by the 
odor of the perspiration, came out of their holes, coiled up around the 
body of the patient, and licked his perspiration without doing him any 
harm. After three or four hours he was taken out of the grotto. 
This treatment was continued until recovery had been obtained." 

It was at this time that neurotic epidemics of mystic enthusiasm 
and of ascetic fanaticism of demonomania began to sadden the world. 

The Cardinal of Lorraine prompted and urged his brother, the 
Duke of Guise, to undertake the extermination of the heretics. The 
Huguenots began to be persecuted with heartless cruelty, and on ac- 
count of their temerity in doubting some of the dogmas of Rome, they 
were brought by scores and by hundreds before the tribunal from 
which was no appeal, and were burned at the stake. This generation 
of heredo-syphilitics gave to the world Catherine de Medici, who, from 
her castle, enjoyed the view of those poor wretches condemned as 
heretics hanging up on iron hooks, or executed in other ways. When, 
after the death of Francis II., the throne came to Charles IX., her sec- 
ond son, who was ten years old, she became the regent, and she had 
every chance for her crafty machinations and bigoted projects, which 
were nurtured by her Catholic fanaticism. 

The Huguenots and the Catholics came to an open war and made 
France a prey to the bloodiest spirits of the age. After the death of 
the Duke of Guise, Catherine, feigning peace with the Huguenots, wa 3 
preparing the most atrocious tragedy. It was in 1565 that she, taking 
advantage of the peaceful conditions of the kingdom, met on a trip the 
Duke of Alva, prime minister of Philip II., with whom she planned 
the extermination of the Huguenots. 

The celebrated night of St. Bartholomew came, the horrible 
butchery of the Huguenots so well and so long planned by Catherine 
commenced. The honored head of Coligny was cut off and sent as an 
acceptable trophy to the Cardinal of Lorraine. The horrible massacre 
lasted seven days, until the murderers, drunk with the blood of thirty 

28 Kircher. " De Arte Magnetica," lib. Ill, quoted by Cesar Cantu. 
" Histoire Univers ," vol. xv, p. 502. 



SYPHILIS IN RELATION TO DEGENERACY 381 

thousand victims, stopped the carnage and went to sing Te Deitm 
I an damns. 

Charles IX. died when twenty-four years old, pursued by his re- 
morses, stricken with terror, continuously recalling the horrible- 
butchery. The third son of Catherine ascended the throne as Henry 
III., w T ho planned and executed the most vile and cowardly assassina- 
tion of his rival, the Duke of Guise, which was followed by that of the 
Cardinal of Guise. He was himself assassinated. 

In Germany Ferdinand I. was elected by the German Diet to the 
throne of the empire in 1558. Under his wise and tolerant rule, 
religious reforms were spreading. The famous Council of Trent after 
eighteen years had finally adjourned. In spite of the cry raised by the 
Cardinal of Lorraine, " Cursed be all heretics," in spite of the horrid 
theory that freedom of thought ought to be crushed by authority, the 
huge specter of mental slavery was gradually vanishing. 

Moreover, when after his death his eldest son took the crown of 
the German Empire as Maximilian II., the hopes of the reformers rose 
still higher. But when Rudolph II., his son, a pupil of the Spanish 
Jesuits, ascended the throne, all changed and the statutes of tolerance 
granted by Maximilian were abrogated. Here again the upholding of 
the decisions of the Council of Trent, that Catholic rulers might pro- 
ceed to put down heresy by the sword. 

England at this time, after the death of Henry VIII. , his son, 
Edward VI., a boy ten years old, having ascended the throne, was 
under the protectorate of Lord Hertford, Duke of Somerset. He, a 
consistent and able opponent of Rome, determined to make the Church 
of England independent of the papal hierarchy and bring the religious 
doctrines and religious ceremonies up to the standard of the Reforma- 
tion. The new liturgy was made to conform as nearly as possible to 
the usages of the primitive fathers of the Church, freed from all osten- 
tatious and superstitious practices of the Catholics, and the ritual was 
in the plain English language, understood by all. 

This, however, put difficulties in the way of the marriage of the 
king, who by the will of his father was to be married to Mary Stuart 
of Scotland. As Catholic influence was predominant in Scotland, the 
demand for the hand of Mary was met with refusal, because the heiress 
to the throne ought never to become the queen of so heretical an island 
as England, and the spouse of so heretical a king as Edward VI. 

It is interesting to note the difficulties and the hardships caused at 
that time among the English social classes through the change of the 
national religion. Difficulties arose in families of the higher class on 
account of their refusing to take up the new religion, as was the case 
with Princess Mary, the daughter of Henry VIII. Helpless monks 



382 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

and nuns were turned out of the doors of their convents and dis- 
possessed of their properties. The peasants, who for a long time had 
rented and tilled the lands of the Church, paying a trifle for the 
privilege, were ruined by the act of confiscation ; and all vagrants and 
mendicants, who at every age have flourished around the doors of the 
monasteries, were scattered in a starving condition. 

Somerset found a great deal of difficulty in contending with so 
numerous a number of malcontents, and for this reason it was easy for 
Dudley of Warwick to arrange a plot against him, charging him with 
conspiracy and leading him to the block. 

Cranmer, who had prepared the English Catechism, guided by the 
works of Luther and Melanchthon, stooped to the miserable work of 
persecution. Two Anabaptists were arrested for heresy, condemned 
by his court, and, in spite of the protests of the king, burned at the 
stake. 

In the middle of the same century we find again in this same 
England Catholicism restored by the machinations of the Queen Mary 
Tudor, who could not find a bigoted husband in England and married 
Archduke Philip of Spain. After the defeat of Sir Thomas Wyatt, 
who wanted to confer the crown on Lady Jane Grey, she had Wyatt 
and four hundred of his followers condemned and executed. Lady 
Jane was also condemned to die, tormented by a priest who had been 
sent by the queen to convert the poor victim from her heresy. 

This same queen and her husband, with their faithful Gardiner, 
formed a plot for the extirpation of the heresy in the kingdom. The 
horrified world saw the burning at the stake of three hundred of the 
most pious and law-abiding citizens. Among them Hugh Latimer, 
bishop of Worcester, and Nicholas Ridley, bishop of Rochester, vener- 
able men, were burned in the public square in front of Baliol College 
in Oxford. 

After the death of Mary Tudor, when the peace and the liberty of 
England were restored under the wise reign of Elizabeth, the rivalries 
began between her and and the queen of Scotland, to give to the world 
the celebrated drama which ended with the execution of Mary Stuart. 

PmTip II. of Spain, after returning from England as the rejected 
husband of Mary Tudor, and more bitter for the rejection of his mar- 
riage by Elizabeth, formed the design to invade England in order to 
destroy Protestantism and restore the shattered dominion of Catholi- 
cism. This design ended like a soap bubble for Spain and in a great 
glory for England. 

Many years had passed in a continuous struggle for supremacy 
until a woman of great virtue, Elizabeth, was able to restore order. 
Since then Protestantism has been the religion of the kingdom, but the 



SYPHILIS IN RELATION TO DEGENERACY 383 

external cult has had a tendency towards the pompous ceremonies of 
the Catholic religion. The austerity of the Genevese reformers did 
not meet the approval of Queen Elizabeth, and for this reason the 
Church of England stands still as a middle point between the Catholic 
and the Lutheran Church. 

At this time a degenerate, a monster of crime and iniquities, was 
reigning in Spain, Philip II., who by inheritance, had one of the great- 
est empires in the world. A Spaniard of the Spaniards, with his eyes 
constantly cast on the ground, it is said that he laughed only once in 
his life, when he heard of the massacre of St. Bartholomew. 

Holland at that time was under the crown of Spain, and as the 
people had accepted cordially the doctrines of Luther, they were made 
the object of persecution. Philip ordered the Inquisition established 
in the different provinces, and to proceed with all rigor against heretics. 
The task was given to Fernando Alvarez, Duke of Alva, the most 
cruel, relentless and infamous of all bloodhounds, who discharged the 
duty to the satisfaction of his master. Crime and blood were the work 
of Alva ; the people belonging to the lower classes were hanged, the 
nobles were beheaded, and the heretics were burned at the stake. 
Reaction came and the Prince of Orange took the part of the oppressed 
beggars. Here the world was astonished by the continuous butcheries 
in Flanders, until the Prince of Orange gained possession of the gov- 
ernment. We cannot enter into a detailed reproduction of the history 
of the sixteenth century, we only want to recall the outrages against 
humanity committed at the sieges of Utrecht, Maestricht and Ant- 
werp. And as if these carnivals of blood had not been sufficient, the 
Netherlanders began to divide into factions and instead of opposing 
the hated Spaniards, engaged in war among themselves. 

It is beyond doubt that at these times when syphilis was spreading 
as an epidemic amongst the populations, as Tommasoli said, there was 
enough reasons for all to have an exceptional vulnerability of the 
nervous system. 

To find some arguments so as to state that syphilis could have had 
some influence on the decadence of the nations during and after the 
sixteenth century is a difficult task, because the disease in those, times 
was very little or hardly known at all, and its influence on the nervous 
system was not even suspected. We lack descriptions, biographies, 
clinical histories, which could afford us some light on so difficult a 
question. As a consequence, we are obliged to approach this subject 
by arguments of analogy, and after we have seen the results of syphilis 
on the nervous system in our own patients, we can apply our conclu- 
sions to the nations in those times. 

In the course of our work we have seen the remarkable influence 



384 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

of the syphilitic process on the nervous system. This begins from the 
first secondary manifestations as toxic poisoning, and ends with the 
late tertiary symptoms, as infiltrations and hardening of the blood 
vessels and of lymph vessels of the central nerve organs. We have 
seen, furthermore, the deleterious influence of the syphilitic infection of 
the parents on the health and development of the children. This in- 
fluence we have seen does not stop at the second generation, but 
descends to the third, giving us a class which we have called heredo- 
syphilitics. Syphilis so transmitted is no longer revealed by the well- 
known symptoms, but mostly through deformities, aberrations from 
the ordinary type in the development of the organs of the body and 
peculiar nervous symptoms, and through extravagances of a psychical 
order, which must be attributed to the sad heritage. 

We have seen idiocy and epilepsy in all degrees and forms affect 
children, and remain during their whole life, as the result of inherited 
syphilis. 

In the psycopathology of epilepsy we know how much influence 
this disease has in producing mental derangements. We have noted 
an epileptic mania, which is so terribly dangerous not only for the 
individual himself, but for others, as it is accompanied by a homicidal 
tendency. The most brutal crimes, the most cruel butcheries, are per- 
petrated by epileptics, on account of their penchant for committing 
acts of violence without a reasonable motive. We have likewise seen 
the influence of the epileptic attack on the crime which may be con- 
sidered a part of the epileptic fit. 

In our times epilepsy has been found to wield great influence on 
the eccentricity of some persons. It has furnished a reason for the 
theories of men of genius, for the exaltations of some enthusiasts, for 
the asceticism of some religious eccentrics. It has furthermore been 
alleged as a cause in the production of the perverts and of the large 
class of the degenerated. Epilepsy is found in families of criminals 
and is transmitted in a hereditary way. Dr. R. de Rocchi 29 referred 
to the history of a family where the first of three generations was an 
epileptic. He had been an embezzler and a thief. Of his five children, 
the third was an epileptic. Of his nephews, two were epileptics, and 
in all were to be found criminal tendencies of the old stem. They 
were of an uncontrollable psychical impulsivity, very quarrelsome, and 
inclined to wound others with intent of killing. 

The forms of epilepsy are so various and different as to be in 
many cases difficult to recognize. In some cases the epileptic begins 

29 Rinieri de Rocchi. " Storia di una famiglia per tre generazioni." Arch, 
di Psich, 1895. Qnot. by Lombroso. " L'Uomo Delinquente," 1897. Vol. iii. 
p. 657. 



SYPHILIS IN RELATION TO DEGENERACY 385 

to feel signs which precede the attack, he has malaise, sexual ex- 
citement noise in the ear, confusion of the eyesight, and at once opens 
his clothes and begins to masturbate, until with a sensation of satis- 
faction, he has obtained his purpose. He then remains stupid, as if 
he had awakened from a deep sleep, begins to cry, and does not recol- 
lect anything of the occurrence. This has been an epileptic attack, 
which has also been called an epileptic equivalent. 

Ottolenghi, 30 among 250 criminals, found 80 of them epileptics 
showing various forms of the disease. In 31 the attack was of a 
convulsive and motor order, and in 76 it was of a psychical nature. 
In 20 the attack consisted of epileptic vertigo, with inconsistent auto- 
matic acts, not violent in character. In 16 there was found ambulatory 
tendency, procursive epilepsy. In 9 the attack consisted in fleeing, and 
in 7 the form consisted in vagabondage, tramping around in idleness. 
In 25 there was found the true epileptic wrath with severe attacks, 
during which crimes of blood had been committed. 

Every one of these epileptic criminals showed clear marks of 
degeneracy, and their sensibility was found greatly diminished. In 
fact, in all those epileptics, the sense of touch, the general sensibility 
and the sensibility to pain has been found stunted and little developed. 

Indeed, in the criminal epileptics there is oftener found the morbid 
epileptic wrath, which is the exaggeration of the character of the 
born criminal. The epileptic criminals have the anatomical and the 
psychical characters of the born criminals, the complete criminal type, 
and on account of their diminished sensibility they are inclined to 
every kind of crimes, but more often to violent crimes of blood. 

When we consider that syphilis is one of the principal causes of 
epilepsy, we will easily understand the influence which the dreaded 
disease must have had on the successive generations. 

Syphilis produces psychoses of specific nature as a result of spe- 
cific encephalitis, and has also a peculiar influence in the development 
of other ordinary psychopathic conditions. In fact syphilis causes a 
severe depression in the ordinary mind of a degenerate, which will re- 
veal the pre-existing deficiencies and the psychical derangement in an 
intellectual or in a moral sphere. In some cases the mental derange- 
ments do not consist in a defined delirium, but rather in a kind of 
mental excitement, incoherence, extravagance, while in other cases 
there is mental depression and apathy nearing an idiotic appearance. 

In reference to the dangers due to syphilitic insanity Jeronimo 
Galliana 31 referred to a case of a man, who, having had some ante- 

30 Ottolenghi. Archiv. di Psichiatria, 1896. 

31 Galliana, J. " Folies toxiques et infectieuses." XIV. Congr. hit., Madrid, 
p. 30. 



386 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

cedents of psychical derangements, acquired syphilis. After the 
fourth month from the infection, he began to show the most violent 
and excited mental condition. He alleged that he had acquired the 
infection from his intended bride, and in an attack of despondency 
shot her dead. The autopsy revealed no sign of syphilis in the young 
lady, as she was a virgin. 

Syphilis in the secondary period is capable of producing psychical 
deviations in the degenerated, with hallucinations, delusions and 
delirium. Before the syphilitic infection, those individuals have been 
somewhat unbalanced, but the toxic influence of syphilis has driven 
them to a violent insanity. There are cases where no signs of de- 
generacy or of mental derangement are present, but only some little 
deficiency, which is rather difficult to recognize. 

We have seen in another chapter that syphilis causes a moral 
affliction in the man who is infected, tending to lead him to suicide. 
In the moral depression resulting from the peculiar anemia induced 
by the virus, together with the toxins produced by the syphilitic germs, 
we find enough factors to induce mental alienation. 

Many other psychoses are of syphilitic origin because they are 
induced by syphilitic lesions of the cells of the brain. Gummata, 
syphilitic infiltrations pressing the delicate nervous cells, prevent their 
nutrition and cause their atrophy. In the blood vessels, syphilitic 
arteritis is also the cause of hemorrhagic effusions, and also of oblitera- 
tions of the blood vessels, which produce softening of the nervous 
matter. 

The consequence of all these lesions on the nerve cells is dementia, 
which at times is revealed by a strange delirium, at other times the 
demential delirium is accompanied by disorders of the motility. In 
some cases the patients, before showing psychical or motor symptoms, 
have suffered with vertigo or with cephalalgia during the night. Then 
gradually they have shown paralytic conditions of the motor nerves of 
the eye, more especially of the motor communis. In syphilo-psychoses 
the derangement of the ideas and their incoherence are quite peculiar, 
and the delirium is usually of a partial character in the form of mono- 
mania, melancholia, delirium of persecution, suicidal tendency. 

In the life of Benvenuto Cellini we find at first this genius busy in 
designing jewelry, sculpture, literature, always being diligent at his 
work : after he had been infected with syphilis he began to neglect his 
work and to dedicate himself to the art of necromancy. It shows a 
disordered psychical condition and an exalted phantasy, the descrip- 
tion of the devils which he thought he saw in the colosseum and which 
accompanied him home, jumping from roof to roof. 

In reference to hereditary syphilis, we have already seen in the 



SYPHILIS IN RELATION TO DEGENERACY 387 

preceding chapters the great influence this has in the production of 
degenerates, deficients and mattoids, and in the following chapters we 
shall present much more in reference to criminals. We agree with 
Tommasoli and Barthelemy and others that the syphilitic heritage 
acts no less than tuberculosis and alcoholism in the production of the 
degeneration of the human race. 

If we return to consider the beginning of the sixteenth century, 
we see that in the splendor of those intellectual men, of those geniuses 
who brought about the Renaissance, a cloud could be perceived which 
produced shadows in many points. Masi referred to the fact that be- 
fore the era of the Renaissance had begun its decline, a gloomy and sad 
expression could be seen in the features of the last men, a kind of 
mystic preoccupation, a sense of uneasiness, or better, a presentiment 
of impending miseries. Josne Carducci remarked that studying the 
face of the divine Raphael, who young, yet died of a mysterious fever, 
it is easy to recognize a peculiar sadness ; on the face of Michelangelo 
there is printed rage and despite, while Ariosto and Berni in their smile 
reveal deep gloominess and wrath. The features of Macchiavelli and 
those of Guicciardini cannot conceal their moral sufferings. 

The human mind was groping under a cloud of restlessness and of 
uncertainty. Fear has been the enemy of mental achievements, and it 
has ever paralyzed the power of the human genius. At that time 
nobody was safe, nobody had an idea of what the morrow would be. 
It was necessary to please the nobles and the powerful, and do one's 
best not to incur their dislike. As a consequence, the activity of the 
human intellect was restrained, and to the melancholic depression there 
was associated a tendency to artificial manners, which began to mark 
the perversion. 

The studied artificial manners, called after a while mannerisms, 
began to appear in the poetry of Tasso, and is much more evident in 
the writings of Leopardi, both geniuses who had been tortured by the 
world, and mostly by themselves. 

Literary compositions of that epoch were dictated by momentary 
passions, were full of personal exaggerations, lacking in intellectual 
elevation. The years of political and moral oppression were passing. 
and the people were adapting themselves to the circumstances, and 
from the studied mannerisms they began to fall towards a kind of 
audacity. This period began with Bernini, and at the second part of 
the sixteenth century is represented by Borromino. Literature, poetry, 
art, architecture, all betray a kind of delirium, which is the character- 
istic of that century. Hobbes and Molines showed delirium in their 
fatalism. Painters showed a kind of delirium in the lack of harmony of 
their colors, and in their reckless vivacitv. Sculpture and architecture 



388 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

showed it in the barocco style which has been well described as the 
extravagance of the art. 

In science, as in art, there are found only an artificial volubility, 
extravagance, and exaggeration, which clearly showed the delirium of 
that century. The men of distinction in arts and in literature of that 
epoch have in their life manifested signs of melancholia and extrava- 
gance which cannot be considered within the limits of the normal. 
Tassoni, an extravagant poet, having tried all his life to state new 
things, died of melancholia. Jodelle, who wanted to substitute some- 
thing new for the mystery play, morality play and the farce, died crazy 
at the age of forty-one. Chiabrera compared himself to Columbus 
and promised to discover a new world. The more we study that epoch, 
the more we recognize, together with the decadence, some psychological 
features which show mental aberrations. The peculiarity of the 
symptoms, the versatility of the manifestations point to that kind of 
alienation which has been recently known as paranoia. A mental 
disease, so-called by Mendel, which occurs in individuals capable of 
considerable education, even of brilliant acquirements, but yet possess- 
ing a mental twist, which makes them belong to a separate class. This 
affection consists in a structural weakness of the nervous system, nearly 
always inherited, bearing relationship to moral imbecility. 

We have already seen the chronic and progressive nature of 
paranoia, its delusions and hallucinations, while the patient still 
possesses reasoning faculties to conceal his mental aberration. The 
delusions, which are mostly in the nature of persecution, and the 
delirium of an ambitious and fastiduous character, have a chronic pro- 
gressive and systematized course. 

Paranoia shows itself, at times, in adolescence ; at other times, 
later in life ; constituting the two principal forms of paranoia originaria 
and of paranoia tarda. 

It is an hereditary disease, and heredity plays the most interesting 
role in the production of this disease. The disease is of a degenerative 
nature and is the result of any influence or any cause which perverts 
or alters the delicate structure of the nervous system. Syphilis, we 
have seen, is one of the most powerful causes which disturbs the nutri- 
tion of the nervous cells by its toxication and its infiltrating processes. 
And we would not hesitate for a moment to state that paranoia finds 
its preferred ground in heredo-syphilitics. If syphilis is hereditary, 
transmission produces syphilitic epileptics, and for the same reason it 
will produce syphilitic paranoiacs. Indeed, as Tommasoli remarked. 
comparing paranoia with paralytic dementia, many manifestations of 
both diseases show a great analogy. 

The syphilitic psychoses which we have mentioned, and those 



SYPHILIS IN RELATION TO DEGENERACY 389 

which assume a chronic and depressive form, may lead to paranoia. 
In effect, literature, arts and sciences in the sixteenth century show 
some peculiar eccentricity and extravagance which clearly reveal the 
aberrations, or better the hallucinations and the delusions of the 
authors. 

It would take a long time to review the life and the works of the 
many distinguished people of that age who have been quoted as 
examples of paranoiacs. 

From all that which we have considered in this chapter, we can 
state that a new, unknown disease, syphilis, had made its appearance 
amongst the people. The decadence began to appear nearly fifty years 
after this disease had spread in an epidemic form among the individuals 
of the social classes. 

By this time we have two generations ; one which had acquired 
syphilis, and the second which had inherited syphilis. If syphilis at 
our age often affects the nervous system, and is capable of inducing 
psychoses, at that time it could in the same way produce mental dis- 
orders. AVhen syphilis has acted in the individuals as an hereditary 
taint on the descendants of the first or of the second generation, then 
it is capable of inducing forms of psychoses of a peculiar kind Which 
give us the right to consider it the reason for the decadence of the 
sixteenth century. 

If we compare the facts and the men of that time with the men 
and facts of the present, we will probably find a support for our thesis. 

At the moment we are writing a carnival of blood is being enacted 
in the vast dominions of the Czar. The horrors of the massacre of 
Kishinev have not only been repeated, but greatly surpassed. " Kill 
the Jews," have been the words shouted in Vyazma ; and hundreds of 
unoffending Hebrews, who were peacefully celebrating the proclama- 
tion of freedom granted to the people by the Czar, fell on the public 
square massacred by a mob drunk with blood and carnage. The mob 
not yet satisfied with their bloody work, went to the Jewish quarters, 
sacked the shops and broke into their residences, destroying everything 
and committing horrible atrocities. 

Dispatches of the same day, November 2, 1905, refer to horrible 
massacres having occurred in Odessa, where at least 5000 persons were 
killed or wounded in one day. The streets are absolutely unsafe for 
civilians. In the outskirts of the town, the massacre of the Jews con- 
tinues. They are being hunted down in the streets, killed and beaten, 
while their shops are given over to pillage. 

In the Jewish quarters bodies still strew the streets and the side- 
walks. Jewish women and children were hacked to pieces in the streets 
bv an infuriated mob. 



390 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPEClS 



Indeed, nobody will find much difference between the actual con- 
dition of Russia and the times of Philip II. and Catherine of France. 
Carnivals of blood were enacted in those times and carnivals of blood 
are enacted in our times. At those times the Huguenots were hunted 
down in the streets and killed in their own houses ; to-day the Jews 
are the object of persecution. 

The same religious intolerance which to-day marks the horrible 
deeds in Russia flooded Europe with blood at the time of the decadence 
in the sixteenth century. The same sentiments of an exalted fanati- 
cism inspired the first conquerors of the two Indias, and they labored 
under the delusion that the heathen, savages, were of an inferior race, 
they had no right to the sky, sun, earth, or even to their own person. 
Consequently the most cruel and infamous outrages perpetrated on 
them was an act of merit. In all those brutal deeds we can see the 
exalted sentiments of a blurred mind fired by uncontrollable impulses 
arising from material interests and social vices, which have prompted 
in those times and to-day prompt the populace to rob and despoil in- 
nocent people of their properties, under the excuse that they are of a 
different religion. 

For those times we have found that syphilis spreading epi- 
demically, with no treatment or with an inadequate one, and trans- 
mitted to the second and to the third generations, could have produced 
heredo-syphilitics with a tendency to psychoses, with exalted and dan- 
gerous hallucinations. In the same way syphilitic virus, either by 
means of its toxic influence on the nervous system or by the anatomo- 
pathological alterations induced on the vascular system, may have 
prepared men with excitable, exalted, perverted, deficient mental facul- 
ties, capable of any cruelty. 

Can we find anything analogous in our days? 

Doboszynski 32 relates that in the district of Kasan an endemia 
of syphilis has existed for many years. Their habits are dissolute and 
promiscuity of sexual relations is admitted, for the reason that the 
women, at the age of twenty, want to have children. Syphilis is also 
spread by means of domestic utensils, and more especially by cigarettes, 
which the women constantly use. In 1902 the government tried to stop 
somewhat the progress of the disease, and a hospital was founded 
exclusively for syphilitic patients. In one year, in a population of 
11,863, 5 20 cases of recently acquired syphilis came up for treatment. 
The number of cases of tertiary syphilis is enormous and is met with 
in thirty-four per cent, of the cases of syphilis. Of 106 children, 92 
showed manifestations of recent syphilis; in 13 there were signs of 
hereditary lues, and in 1 of tertiary cachexia. 

32 Doboszynski, L. " Przeglad lekarski," 1904. Ref. Monatsheft f. prakt. 
Derm. B. 39, p. 295. 



SYPHILIS IN RELATION TO DEGENERACY 391 

Hyde S3 stated that among European countries syphilis is found 
to prevail extensively in Russia, especially in the large cities of Mos- 
cow and St. Petersburg. The colder climates, where one might sup- 
pose on a priori grounds that the habits of the enervated and effemi- 
nate residents of the tropics would not be countenanced, seem to have 
in the larger centers of population the effect of stimulating the 
passions of men and women densely crowded together in the cities, 
and seeking in drink and debauchery a respite from the cheerlessness 
of an inhospitable climate. 

According to Wwedensky 34 in his study on syphilis among the 
prostitutes of the brothels in St. Petersburg, he found that in 70 of 
those houses there were 689 women actually infected with syphilis and 
273 not infected ; 102 had had syphilis, but were past the infectious 
stage, while 45 showed gummata. In all the houses of prostitution he 
found 39 per cent, of prostitutes in the condylomatous stage capable 
of spreading the infection. 

Sperk, 35 Fedorow, 36 and Graziawsky, 37 in their different reports 
taken from the police department, from hospitals and clinics, and from 
the houses of prostitution, bring the amount of syphilitic prostitutes 
with recent infection up to thirty-nine per cent., showing that syphilis 
in the houses of prostitution is flourishing. In the same way, from 
the testimony of Tarnowski, Petersen and Tschnelow, we may argue 
that syphilis in Russia is widely spread and is a dreadful scourge 
amongst the people. We have already seen that Tarnowski has coined 
the term syphilis binaria to be applied when heredo-syphilitics of the 
second generation acquire a new infection. 

In the higher classes of society in Russia we refer to the report 
of Thompson, quoted by Sanger, 38 morality does not appear to be at a 
high standard. He said, " immorality and intrigue are of universal 
prevalence, and in a social sense are hardly looked upon as criminal 
acts, while gambling and debauchery are the natural consequences of 
the tedious monotony from which all seek to escape by indulging in 
gross and vicious excitement." 

Sanger stated that the conjugal relations of the Russian nobility 

33 Hyde, J. N. " History, Geographical Distribution," etc. " System of 
Gen. Urin.," etc. New York, 1893. 

34 Wwendensky, A. A. " Die syphilis unter den Prostituirten der St. Peters- 
burger Bordelle." Arch. f. Derm, und Syph. B. 36, p. 127. 

35 Sperk, Ed. " Theorie der Statistik bei Erkrankungen und Sterblichkeit, 
und Anwendung derselben zur Untersuchungen der Prostitution und Syphilis." 
Quoted by Wwendensky. 

36 Fedorow, A. " Die Prostitution in St. Petersburg und deren polizeiartz- 
liche Beaufsichtigung." Arch. f. Derm. it. Syph. Bd. 25. p. 395. 

37 Graziawsky, P. J. " Kritische Besprechung des Berichtes von Prof. Tar- 
nowski." Zdorowic, 1881, N. 5, 6. 

38 Sanger, W. W. " The History of Prostitution." New York, iSoo. p. 27$. 



392 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

were extremely loose and indefensible during the time when vice was 
the fashion, and virtue in a courtier would have been deemed con- 
demnation of the higher powers. Then, and even down to the reign 
of the Emperor Nicholas, marriage was simply an affair of convenience, 
the husband living at Moscow or St. Petersburg, the wife in Paris or 
Italy, such separations frequently lasting for years. 

In our study of the extraordinary happenings of the world, we 
have found that syphilis could be accounted as one of the most power- 
ful causes of degeneration amongst the populations of the sixteenth 
century. We have referred to the excitable feelings, to the exalted 
phantasy induced by syphilitic psychoses, the murders, the carnages 
and the pillages of these ages. Now we do not see any reason why we 
should not attribute a good part of the carnivals of blood, of pillages 
and of persecutions which are at present enacted in Russia to the 
excitement of the psychical faculties due to syphilitic disturbances of 
the brain. 

It is not necessary that every one of the infuriated mob should 
be led by a morbid condition of their mental faculties, but the leaders, 
or those instigating them to such atrocities must be afflicted with 
hallucinations and delusions. The insane easily find followers, the 
folie a deux is constantly at hand, and a crazy man with an exalted 
phantasy, with a morbid delirious mind, will find followers in his 
vicious and dangerous delusions. The followers look upon their delu- 
sions and hallucinations as the result of a mysticism, which they 
admire, and yet are not able to comprehend, but which stirs up their 
enthusiasm as if from a supernatural command. 

The thesis is one of too delicate a nature. It is based on the 
results of medical observations without positive data to prove that those 
men of the sixteenth century had shown secondary or tertiary symptoms 
of syphilis. In the same way we have no positive data to prove that 
the leaders of the massacres in Russia were syphilitics, or came from 
a generation of heredo-syphilitics. But one thing is sure, at the time 
of the sixteenth century, many had been affected with syphilis, and in 
Russia lues is quite frequent. It is possible that some, who had their 
minds in a morbid condition on account of the luetic infection, have 
given the start and the others have followed their vicious and delirious 
impulsions — impulsions which have been induced by lues in an ac- 
quired or in an hereditary form, and have been converted into criminal 
acts as a consequence of the stringent political and social circum- 
stances. 

SYPHILIS AS A PREDISPOSING CAUSE OF CRIME 

Criminality should be divided into two principal types, which 
are constantly in relation with the physiology and pathology of the 



SYPHILIS IN RELATION TO DEGENERACY 393 

social spheres. One is called atavic criminality, and is more often 
connected with morbid conditions of the nervous centers, while the 
other, called evolutive criminality, is also perverted in the intention, 
only somewhat more refined in the means. The first form uses violent 
means, struggle, homicide, rape, theft, while the other substitutes 
keen fraud and deception for violence. 

Heredo-syphilitics are in general predisposed to the first form of 
criminality, while anyone who has a weak moral character, who is 
unable to resist a bad influence, is liable to fall into the second kind. 
A defective condition of the mind is connected with an arrest of de- 
velopment in the organs of the brain, which hereditary diseases and 
especially syphilis may induce. Indeed, as Clouston suggested, the 
tissues which mature slowly are more likely to be affected by hereditary 
disease. When the circulation, especially that of the capillaries, is 
impaired, growth and energy itself may do harm, because they cannot 
be properly distributed and rightly proportioned. When the distribu- 
tion of the nutrition from the blood is not rightly done, then each 
determinant cannot obtain its full share of the momentum and there is 
disproportion. Thus it is that in heredo-syphilitics we sometimes see 
the gain in height at the expense of the weight, or an arrest in the 
general development, as in infantilism ; at other times the lack of 
development affects the nervous system, which is left immature or not 
evenly developed. 

For these reasons the heredo-syphilitics on the one side, on account 
of the true pathological condition of their brain may be predisposed to 
the first kind of criminality, but it is not impossible that on account of 
an undeveloped condition of the brain they are likewise predisposed to 
the second. 

Lombroso referred to the observations of Sighele, 39 which show 
that the two forms of criminality are also found in associated criminal- 
ity ; the first, in the lowest classes, and the second, in the higher classes 
of society. On the one hand are rich people, politicians, etc., who 
bribe or receive bribery, by means of intrigue and deception steal the 
public money, and on the other hand are the poor and the ignorant, who 
in anarchistic meetings, in riots, etc., are trying to rebel against the con- 
ditions imposed upon them, and protest against immorality. The first 
form of criminality is essentially evolutive in character, the second is 
atavic, brutal and violent. The first comes from intelligence, rests on 
cunning means, such as embezzlement, fraud, etc., the second rests 
on the muscular powers and ferocious means, such as homicide and 
dynamite. 

In the Middle Ages we find the records of a bloody criminality, 

39 Sighele. " Delinquenza settaria." Arch, di Psich. xvi, 1805. 



394 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

which we have seen reproduced at this time in the unhappy Russian 
domains. The uncivilized conditions of the populations, and much 
more so of the governments, which have organized and maintained 
barbarous means of repression, are the cause of the association of 
criminals. Indeed, as Azeglio 40 stated, when the royal mail service 
used to defraud people with the letters, when the police were busy 
arresting honest patriots, w r hile leaving undisturbed thieves and high- 
way robbers, and allowing every transgression in the brothels and in 
the prisons to go on freely and unrepressed, there came as a necessity 
the protection found in the mafia or in the camorra, which was a 
natural adjustment of the people to the political conditions. 

The brigands represented a kind of savage justice against the 
oppressors. In Russia, the moujik, indifferent of his life on account 
of continuous sufferings in which nobody had ever taken any interest r 
was ready to commit murder to avenge his wrongs. 

In Italy, the wrongs committed by the landlords against the 
peasants formed one of the principal causes for the existence of the 
brigands. The poor peasants saw T in the brigand a man who redressed 
their wrongs. The communities which had been well administered 
did not furnish a single brigand, while those badly administered 
furnished large numbers of them. In provinces or in counties where 
the law shows inefficiency, a class of people of the most daring believe 
themselves superior to the law, and as a consequence the others be- 
lieving the law inefficient take the law into their hands. Kentucky has 
given us many instances of this in late years in its family feuds, and 
several other States in their lynching parties, as a protest against the 
inefficient administration of justice. 

In Rome, for instance, criminality was far greater than in anv 
other province of Italy. It was the result of the traditional impunity 
which was accorded by the fallen papal government. The common 
people of Rome, steeped in religious superstitions and lacking in in- 
struction, were incapable of restraining their passions and of consider- 
ing the results of them. A word uttered while playing cards, a sus- 
picion of infidelity or rivalry in business, was sufficient reason for the 
commission of murder. The cause was so disproportionate to the deed 
that often the judges have considered it an attack of sudden insanity. 
A few glasses of wine kindled the ire for any imaginary offense, the 
stiletto or the knife was readily at hand, and the reason was too much 
blurred to refuse its services and consider the sad consequences. This 
proclivity to crimes against persons, this disregard for human life was 
also increased by the barbarous superstitution, that whoever dare not 
take revenge for an insult is no man, that manly dignity obliged one 
40 Azeglio, M. Quoted by Lombroso. " Uomo delinquente " vol. iii, p. 49. 



SYPHILIS IN RELATION TO DEGENERACY 395 

to take justice in his own hands and not seek it through the legal 
authorities. It was the inheritance of violence, the atavic brutal in- 
stinct handed down from the old Romans. 

In any civilized country every decent man believes it his duty 
to assist the police to apprehend a thief or a murderer, but the lower 
classes of the Roman population, who were unable to understand the 
government, would either kill him, or, entirely unconcerned, would let 
him go. Tommasi-Crudeli related that in Sicily the name of malan- 
drino culprit lost the significance of infamy, and was applied by the 
people as a name of praise, meaning by it a man who has no fear, 
especially of justice, which in their blurred minds is confused with the 
government. 

In Corsica murders for revenge are exceedingly frequent and the 
causes are scarcely credible. Bournet 41 related that a dog belonging 
to Tafani which was killed by Rocchini, caused eleven victims in the 
two families. Nobody^ in order to help justice, would testify concern- 
ing a crime which they had seen. 

The increased civilization of modern times increases wants, and 
consequently wishes, in the people, who seek gratification in sensual 
excitement. It is not to be wondered at to-day that the number of 
those suffering from alcoholism and general paralysis is increased in 
the asylums, just as is increased in the penitentiaries the number of 
culprits against property and against morality. This kind of criminal- 
ity is mostly found in the large cities, and mostly in the educated social 
classes. 

The facilities for traveling, the railroads and commercial con- 
centration have tended to enlarge the centers of population. Delin- 
quents have found their way to the large cities, where they expect to 
find better profits and greater immunity. This, however, is not so, 
because if the incentives to crime are increased, vigilance and repres- 
sion are also increased. In the large cities more facilities for work are 
offered and also more seductions are at hand. But, as Lombroso 
thinks, the conglomeration of population acts a great deal as one of the 
causes leading to crime and immorality. 

Indeed, every one of us has had occasion to remark that a man 
who in his home is modest and reserved, in company with others may 
talk licentiously and even immorally. Moreover, it has occurred that 
men have stolen or committed immoral acts just to show to the others 
that they are good companions. This tendency is increased with the 
increasing of the masses, and it finds its proof in the fact that manu- 
facturing districts show a larger number of crimes than rural districts. 

Bertillon remarked in every man a certain violent or morbid tend- 
41 Bournet. " Criminalite en Corse," 1887. Arch, di psich., viii. 



396 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

ency to reproduce the sentiments and the passions which are fomented 
in our surroundings. It seems that the air, filled with the dominating 
opinions, acts as it does with contagious diseases. 

A faint instinctive tendency to theft, to homicide, and to lascivity 
is found in embryo in every individual, which disappear when culti- 
vated by education. These embryonic bad tendencies may at once 
assume greater proportions in company with others. 

It is found that in the schools and in the colleges the most virtuous 
learn from one or another the mysteries of vice. The relative develop- 
ment of the brain, together with the functions of the sexual organs, 
explains the tendency to offense against morality. The quantity of 
prostitution in the large centers finds its cause in the congestion of 
population. The increased use of alcoholics and of tobacco, and to-day 
the horrible use of opium and cocaine are other causes of the increase 
in crimes. 

The studied and well-arranged description of crimes in the news- 
papers is in many cases the cause of excitement and of a desire of 
emulation in the criminals. Quite often we have heard from criminals 
that they wanted to do as Tracy or Jesse James did, whom they consid- 
ered their heroes. The reading of dime novels, dealing mostly with 
criminal deeds, kindles the passions of the young people and leads them 
to misdeeds in imitation of their hero. In the same way the sensational 
performances in cheap theatres have a great influence in kindling the 
passions of the young theatergoers and prompt them to commit some 
misdeed. The crowding of men in the poor lodging houses, their dis- 
cussions on social problems, are often the cause of strikes and then of 
being led to theft. 

Bringing criminals together in jails and in penitentiaries makes 
them much more dangerous and daring. Among the inmates of the 
penitentiaries the greatest perversity is a glory, and any idea of virtue 
is a shame, and when a man has been in jail for some time, if he had 
good ideas, very likely they are lost. 

Yet philanthropic reforms, conditional liberty, discharge on parole, 
have not so far given very good results. The born criminal has certain 
conditions in the organization of his brain which prompt him to commit 
crime, and anything which is done with the view of elevating the manly 
dignity remains inefficient on the bad disposition of those criminals. 
On the contrary, when a criminal can have the hope of escaping punish- 
ment, he is more incited to crime. Armengol 42 wrote that Spain was 
a free penitentiary, where everybody could commit any crime without 
fear of punishment. By political influence, liberty could easily be 
obtained, and crimes increase to an enormous extent. 

42 Armengol. " Estudios Penitenciarios," 1873. Quoted by Lombroso, /. c. 



SYPHILIS IN RELATION TO DEGENERACY 39; 

The progress of civilization is not to be called responsible for the 
increase of crime. It is possible that under a wrong interpretation 
some may see in the high degree of civilization an increased looseness 
in the family ties, and as a consequence an increase of illegitimate 
children, who, when adults, often join the ranks of criminals. Licen- 
tious ideas of the family ties are often the cause of an increase in rapes 
and in infanticides. On the other hand, the work of philanthropists, 
the work of the societies protecting children, are the means which 
society opposes to crime in its incipiency. 

The density of population plays a great role in the number of 
crimes. Wherever people live far apart, theft, infliction of wounds 
and prostitution are rather rare. But with the contact of families in 
tribes or clans, crime shows up in a ferocious manner with great fre- 
quency. The question is one of the occasion which the contact affords, 
an occasion which is lacking when the density is greatly reduced. 
Yet according to Lombroso the homicides are diminishing in the large 
cities, with the increase of the density, and are very frequent in 
sparsely populated places, where ignorance and barbarism are domi- 
nant, and the killing of a man is considered rather a duty than a 
crime. Thefts, rapes, violence against the officers of the law diminish 
with the increase of density of population, but on some occasions are 
frequently met with in the capitals and at times in great manufacturing 
centers. 

In France, the study of the relation of the density of the popula- 
tion to the monarchical reaction has shown that in the most densely 
populated districts the public is more inclined to revolutionary ideas. 
It is clear that in the most crowded districts political agitations are 
most frequent. For this reason the large cities are dangerous to the 
political conditions. The highest proportion of revolutionists is ahvays 
found in the districts where the population is overcrowded, while in the 
rural districts where the population is sparse, people have conservative 
ideas. Great cities are dangerous to political quietness, and as stated 
by Maxime Du Camp, France has too big a head and like hydrocephalic 
individuals is subject to maniac fits. 

We have already shown that syphilis is more common in large 
cities than in rural districts. We have found that a great percentage 
of the population have suffered from syphilis, and a great many of their 
children are heredo-syphilitics, who show prominently the marks of 
degeneracy. 

Amongst emigrants we find syphilis very common. In our private 
practice, hospital and clinics, we have had occasion to ascertain that 
syphilis is the principal cause of the ailments among Italians and 
Irish of the lower classes. Emigration itself is an occasion for crime. 



398 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

and when there is already a predisposing one in the system, then we 
will not be astonished at the increase in crimes in the States where 
most of the emigration goes. 

In the Compendium of the Tenth Census of the United States, 
the States where Irish and Italian emigration is directed, have given 
the highest number of crimes. California comes first, with 0.30 con- 
victed to 1000 inhabitants, having 33 per cent, of emigrants. New 
York comes next with 0.27 convicted to 1000, with 23 per cent, of 
emigrants. In New York, of 49,000 arrested, 32,000 were emigrants. 

In France it has been remarked that among 100,000 residents in 
their native place, 8 were indicted, while living outside of their native 
place 29 had been indicted, and among 100.000 foreigners living in 
France, 41 were indicted. 

When the emigration from one country to another is in limited 
proportions, it usually carries men of intelligence and energy, but when 
the emigration is too large, the good and the bad elements are un- 
doubtedly found mixed together. 

Emigrants who have no intention of assimilating with the people 
of the country, and only intend to remain as temporary emigration, are 
the most dangerous, and often give the larger number of criminals. 
The most dangerous class of emigrants has been found to be those who 
have no trade or profession, but at random accept any kind of work. 
In France, emigrants who take up peddling have given the larger num- 
ber of crimes, frauds, and violence. 

Some emigrants, as Joly 43 remarked, arrive in large cities with 
good, honest intentions, but allured by the new surroundings are liable 
to make a mistake which will drag them over the precipice into crim- 
inality. A poor girl succumbs to seduction and becomes a prostitute. 
A workingman has lost his job, remains idle, becomes acquainted with 
bad companions, wants to enjoy pleasures with them, and becomes a 
thief. These are only occasional criminals in whom the predisposing 
cause has not much importance. People we are now considering are 
those who come to the large cities purposely to commit crimes. In the 
larger cities, occasions for crimes are constantly at hand, and the 
crime can be committed in so disguised a manner by frauds as to 
scarcely resemble an evil. 

Lombroso, in speaking of the emigrant, said that he belongs to 
that human agglomeration which has the greatest inclination to asso- 
ciated criminality. He has more needs, less surveillance, less shame, 
more facilities to escape justice, more frequently uses jargon, and has 
a tendency to wander. Pilgrims for religious purposes in Italy have 
committed a large number of crimes. Lozzi refers to the name 

43 Joly. " France Criminelle," 1890. 



SYPHILIS IN RELATION TO DEGENERACY 



399 



mariolo, which in Italy is a synonym for scoundrel, as derived from 
those pilgrims, who used to sing Ave Maria while committing rapes 
and thefts, which they intended to expiate with the penitence of the 
pilgrimage. 

The crimes committed by pilgrims were so appalling that the 
king of France, in 1732, by a special decree, forbade pilgrimages to St. 
James of Gallicia, and to Notre Dame of Loretto, which were consid- 
ered^ the cause of crimes. 

In the provinces where the birth rate is very low criminality is 
greatly increased. Indeed, the lack of population caused by that 
diminished birth rate is replaced by emigration, which causes associated 
criminality and the rate of crime is suddenly augmented. In Cette and 
Marseilles, as observed by Joly, the birth rate has been greatly reduced 
and the emigration greatly increased, with an enormous increase in 
criminality. It has been found that in the provinces where are most 
early marriages and more legitimate children, the number of crimes is 
diminished. 

Syphilis is usually acquired on account of the alleged necessity of 
waiting for marriage. The man has not yet a position sufficient to 
support a wife and family, and marriage is considered out of the ques- 
tion until late in life. In the meanwhile, he must run around and see 
something of life, and one day or another he will be caught and syphilis 
will, be acquired. This is another cause of delay for marriage, as 
we have already shown, and in many instances a cause for sterility. 

In this case, if syphilis is not the predisposing cause to crime, yet 
with the hindrance which it is liable to cause in the family, may result 
as an indirect cause of increasing criminality. 

In the. negro race syphilis is so common that from our observa- 
tions we would venture to state that over fifty per cent, of the colored 
population are syphilitic. In colored families syphilitic hereditary taint 
is clearly shown, and in our hospital work we find colored men or 
colored women who, together with lesions from hereditary taint, show 
secondary symptoms of recently acquired lues. They afford to us the 
most striking examples of syphilis binaria, so called by Tarnowski, 
which is quite often revealed on their internal organs in the form of 
visceral syphilis or on the nervous centra. Epilepsy in all its forms is 
quite common in the negro race ; they often indulge in alcoholics, which 
with syphilis, lays hold of them in violent attacks which lead them to 
crimes. Atavic criminality is the common form of crimes in the negro. 
Burglary, rape, theft, homicide of the most violent character are fre- 
quent amongst them. 

In 1889 there were committed 3296 prisoners for different offenses 
to the Cincinnati workhouse. Of these, 2828 were white, and 468 were 



4 oo THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

colored. The total population of the city was 325,000, of which only 
14,482 were colored. On this basis the white prisoners were less than 
I per 1000 to the white population, while the colored prisoners were in 
the proportion of over 3 per 1000. 

So far all jurists who have worked on the subject of the increase 
of homicides have assigned as causes the sentimental enforcement of 
the law, whereby many escape full punishment. Yet we see that the 
death penalty by hanging or by electrocution has no deterrent action, 
and murders are constantly committed. 

The attempt upon human life, and even suicide, must be consid- 
ered in most cases as due to an aberration of the human mind. The 
rash act committed in a moment of passion is after a while greatly 
regretted. This feeling of repentance shows that the man who has 
committed the crime has done it under different influences, which have 
for a while destroyed the control of his will. One of the principal 
causes, in our opinion, is the pathological condition of the nerve cells, 
which we have already seen greatly influenced by the toxins of syphilis, 
or by the condition of their nutrition induced by the alterations of the 
blood vessels. 

Where syphilis is most widely spread, there degeneracy is most 
frequent, and where degeneracy is oftenest found, criminality fills the 
ranks of society. The more we study man the more we find that moral 
qualities are ultimately dependent upon physical conditions, which in 
some cases can be fully ascertained. 

Crime as a disease of society has its predisposing and its occasion- 
ing causes ; the anatomo-pathological conditions of the sensory organ 
is the predisposing cause, while the adverse social conditions are the 
occasioning circumstances. A man who has his mental faculties in 
perfect order, in adverse social conditions will worry for a while, then 
take courage, resist and conquer. The man who is defective in his 
mental organs, with a deficiency in his will power, with a superexcitable 
nature, is unable to control the impulse, succumbs to the adverse cir- 
cumstances and commits crime. 

There is good reason for saying that a direct relation between 
syphilis and crime exists. We have already seen in the previous 
chapters that epilepsy, general dementia, and varied forms of insanity 
are affections of the nervous system, which recognize syphilis as the 
determining cause. Epilepsy we have seen so intimately connected 
with crime that an epileptic is always to be considered as a dangerous 
member of society. In these cases the crime is independent of the 
will of the epileptic, the deed done in a fit of the disease, and after the 
crime is committed the epileptic has scarcely any recollection of the 
deed. In a family an epileptic son attacked the father with a poker,. 



SYPHILIS IN RELATION TO DEGENERACY 401 

and after wounding him severely alleged that he had received a com- 
mand from God to kill his father. 

In many instances the psychological symptoms due to syphilis do 
not constitute a true mental alienation, but the patients are only 
excitable, exaggerated, extravagant, so much so that it is difficult to 
establish what is true insanity and what is not. 

We have already mentioned a chronic form of syphilitic insanity 
described by Fournier as intellectual asthenia, where a remarkable 
depression or mental weakness takes place. To the same syphilitic 
cause is to be referred incoherence of ideas, with partial delirium, the 
idea of persecution, with a suicidal tendency, as is often found in 
paranoiacs. 

The existence of moral insanity admits no doubt, and in many 
cases it is the result of syphilitic alterations of the blood vessels. 
Lombroso referred to the anatomo-pathological reports of Sandou, 
Laseque and Bonvecchiato, who in three autopsies of three cases of 
patients with moral insanity found meningitis, foci of softening, of' 
apoplexy, and more particularly an advanced condition of arterio- 
sclerosis. 

Arndt 44 found many cells of the neuron not completely developed, 
and the axis much smaller than usual surrounded by infiltrating cells, 
without the necessary isolation from the surrounding tissues. In some 
places the homogeneous appearance of the nerve fibers is lost and they 
are studded with inflammatory cells. The blood and lymph vessels are 
greatly altered in their tissues, which causes blood congestion, stasis 
of the lymph serum, and pressure on the delicate structure of the cells 
of the neuron. 

The alterations of the circulation anatomically show the impaired 
development of the neuron, and moreover explain the perversion of 
the sensibility of the will. The lack of nervous conductibility and of 
reaction such as apathy and analgesia are the result, but on the other 
hand the nervous activity may temporarily increase and give a sudden 
flash in the form of impulsion. We have already had occasion to refer 
to the studies of Hubner on the alterations produced by the syphilitic 
virus on the blood vessels, and consequently we must recognize syphilis 
as one of the most effective causes in the production of moral insanity. 

These degenerates are the most dangerous class of criminals. 
Being morally insane, they take as their specialty any criminal act to 
which their impulses may prompt, without any regret and often without 
cause. Crimes are committed in the presence of others, and in some 
cases as an alleged public benefit, instantaneously with irresistible 
impulsiveness. 

Guiteau wrote, that " when the mind is possessed by inspiration. 
44 Arndt. Virchozv's Archiv., 61, 67, 72. 



4 02 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

the mind is not able to reflect. Before, I had horror of a murder, but 
later I understood that it was a true inspiration. . . . For fifteen 
days I was inspired, I could not eat nor sleep until I executed the 
deed, after which I slept soundly/' 

Our object is not that of finding an excuse for crime in a pre- 
disposition caused by syphilitic taint, or by the syphilitic virus, in those 
who have criminal tendencies. Neither do we want to defend them 
on the ground of the limitation of free will, which is subject to the 
anatomical and pathological conditions of the nervous system, but we 
must emphasize the fact that the psychical functions are greatly im- 
paired in consequence of acquired syphilis and much more so in that 
of hereditary lues. 

Inquiring into the reports of Czolgosz, we find the assurance of 
the greatest experts, such as McDonald, Hurd and others, on his being 
of a sane mental condition. Yet considering the enormity and bru- 
tality of his offense, the cynicism shown, we cannot fail to see that 
he belonged to the class of the obnubilated, and of the morally insane. 
His photograph published by Harper's Weekly, and the photographs 
of the casts accompanying the report of the post-mortem examination 45 
show a slightly uneven development of the right eye, which is some- 
what uneven with the left. In accordance with our views this scarcely 
perceptible dystrophy might have been the result of a periostitis of 
the orbits in his infancy, which would have had as cause a syphilitic 
taint. Moreover, in the examination, McDonald 46 wrote that he found 
two flat, unindurated cicatrices on the mucous surface of the prepuce, 
probably the result of previous chancroids. Here is an extremely im- 
portant point for us, for nobody is able to distinguish whether a scar 
is the consequence of a chancroid or of a hard chancre. Nobody can 
persuade us that those cicatrices were not the result of syphilitic initial 
papules, as the door of entrance for the virus. He denied having con- 
tracted any venereal disease, but the cicatrices were there. The finding 
of all organs perfectly normal does not exclude the possibility of 
spirochaetse in the system or of toxins in the blood, which affect the 
nervous centers. 

The blurred ideas of an ardent anarchist, which he proclaimed in 
his reply, " I don't believe in the republican form of government, and 
I don't believe we should have any rulers," show clearly an exaltation 
and an extravagance bordering on the abnormal condition. 

We are greatly indebted to Dr. D. Este Weatherhead, physician 
of the Hamilton County Jail, who gave us a list of the criminals there 

45 Spitzka, E. A. " The Post-mortem Examination of Leon F. Czolgosz." 
Medical News, Jan. 4, 1902. 

46 McDonald, Carlos F. " The Trial, Execution and Mental Status of the 
Assassin of President McKinley." Medical News, Jan. 4, 1902. 



Plate XV 




Leon F. Czolgosz 

(By courtesy of Harper's Weekly') 




Stigmata of Degeneracy in a Criminal 



SYPHILIS IN RELATION TO DEGENERACY 



403 



detained. In some of them syphilis has left indisputable signs, or is 
still present, or there are marks of hereditary taint. 

J. J., colored, convicted of highway robbery, was infected with 
syphilis for several years, has at present multiple ulcerated gummata 
of the legs, and signs of periostitis of the scalp. 

Wm. W., colored, convicted of murder, acquired syphilis five years 
ago; his skin still shows pigmented spots of papular eruption. 

J., C, and D., whites, are three criminals on trial for murder, 
hold-up and highway robbery; all three acquired syphilis between two 
and three years ago. 

C. S., colored, convicted of murder, has unmistakable signs of 
hereditary lues in the shape of his tibiae, in the condition of his teeth 
and in the shape of his skull. He contracted syphilis three years ago. 

W. B., colored, convicted of murder and sentenced for life, shows 
signs of hereditary lues. 

H. S., colored, convicted for murder and sentenced for life, has 
hereditary syphilis, and is subject to slight epileptic attacks. 

C. T., colored, up for grand larceny, bears signs of hereditary 
syphilis, and has symptoms of recently acquired syphilis — syphilis 
binaria, Tarnowski. 

The accompanying picture is that of a man twenty-nine years 
old, who has been in the toils of justice over nine times for 
drunkenness, disorderly conduct, assault and battery. Clinical history : 
the shape of his head and the peculiar malformations show the com- 
plete type of the degenerate, and of mental inferiority. His face is 
asymmetric, the ears of Morell type, the palate narrow, elongated and 
very high, with a scar and a perforation behind the incisors. The 
teeth are badly implanted and are of the notchy type. The crests of 
both tibiae are rough and show exostoses. 

His sensibility is dull, memory very poor. He claims to have been 
four years at school, but has forgotten how to read and write. He 
claims never to have had coitus, and not to feel any inclination for 
sexual relations. 

It seems to us that he can be referred without hesitation to the 
class of heredo-syphilitics. Syphilis, alcoholism, degeneracy and 
criminality from parents to sons are shown to be transmitted by heredity 
in all classes and in all stages of society. Syphilis is mixed in those 
criminals either as acquired or as hereditary taint, in many cases both 
together ; in others we cannot deny that syphilis in the third generation 
is capable of producing limited alterations in organs or in the nervous 
centra so as to cause physical as well as moral monstrosities. 

We have already maintained that in the negro race syphilis is 
more prevalent in all its aggravated forms; in their families hereditary 



4 04 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

syphilis is very common, and also criminality of an atavic type is more 
frequent, burglary, rape and homicide being often committed. 

To show the importance of heredity in the maintenance of crim- 
inality in the families, it is interesting to refer to the studies of 
Dugdale 47 concerning the infamous Max Juke family, showing that 
from one drunkard as a stem, came 200 thieves, 280 paupers, 90 pros- 
titutes, and nearly every one was infected with syphilis. 

Epilepsy is often found in the parents of criminals. Knecht in 
400 criminals noted 60 epileptic parents, and Ribaudo among 559 
criminal soldiers found epilepsy in the parents in the proportion of ten 
per cent. 

Alcoholism, when associated with syphilis, is also a most important 
factor in crime. The deleterious influence of this combination is so 
great that French authors have made a special kind of syphilis, which 
they call la syphilis alcoholisee. The excessive craving for alcoholics, 
the impossibility of controlling himself from the abuse of them, forms 
in itself a form of mental alienation called dipsomania. The irritating 
action of the alcohol on the nervous system makes syphilis much more 
virulent and attracts its deleterious action to the nervous system, pro- 
ducing delirium, delusions, progressive dementia, epileptic attacks, etc. 

A strange relation exists between syphilis, crime and prostitution. 
In some cases syphilis, causing sterility in the mother, or the death of 
the child, can be considered as a providential law to stop in some 
families the monstrosity of crime. 

Prostitution, which frequently cannot be explained or excused by 
poverty or by special accidents, is to be attributed to hereditary syphilis. 
As prostitution and crime go hand in hand, in the families where the 
brothers are criminals the sisters are prostitutes. Syphilis is thus the 
tie between crime and prostitution, when it causes the affections of 
the nervous system, resulting in moral deformities. Syphilis is pre- 
dominant above every other type of disease, and when it induces in- 
sanity or epilepsy in the form of cerebral syphilis it must at the same 
time be considered as a predisposing factor to crime. 

It will be found of some interest to compare the criminal records 
of Chicago and New York for the months of January and February, 
1906. 

Chicago New York 

Murders 22 18 

Burglaries 840 400 

Robberies 216 20 

Assaults on women 30 26 

47 Dugdale. " Thirtieth Ann. Report of the Execut. Com. of the Prison 
Assn. of New York." 



SYPHILIS IN RELATION TO DEGENERACY 405 

The population of Chicago is calculated at 1,990,750, and that of 
New York at 4,014,504. 

In the reports of the American Dermatological Association we 
find that in the line of syphiloderma, Chicago has reported 526 cases, 
while New York has 349 cases. In proportion to the population it 
shows that Chicago has more syphilis and more crime than New York. 

Syphilis is also connected with pauperism. In ordinary hospital 
practice a great many once infected with syphilis show deformities, 
ulcers, visceral complications, and are compelled to remain as inmates 
in the Hospital. In the poorhouse a great many cases of ulcers of 
the legs, of elephantiasic condition of the legs and genitals, are but 
the result of syphilis which the patients acquired in their young days. 

As a consequence of old syphilis or of an hereditary taint, many 
are affected with syphilitic psychoses, such as to make them inclined to 
crime and vagabondage. 

When we are fully aware that syphilis as a highly contagious 
disease can be acquired not only intentionally, but also accidentally, 
without fault of the individual infected, when we know that syphilis 
increases the ranks of paupers, of prostitutes and of criminals, there 
comes as a consequence the conviction of the necessity of stamping out 
so dangerous a disease. The ridiculous utterances of some hypocrites 
must not prevent the work of municipal governments in adopting all 
means for diminishing the spreading of this sordid and abominable 
disease. 

SYPHILIS AND SEXUAL PERVERSION 

Just as prostitution, perversion too has its reasons in degeneracy. 
Degeneracy we have seen to be greatly the result of syphilis in one 
form or another. The perverted form a class of sexual neurasthenics 
who have an uncontrollable tendency to satisfy their sexual appetites 
in a strange, unnatural and brutal manner. They are insane, and of 
a dangerous class, against whom society has to protect itself. They 
are criminals against their will, and they should not be persecuted, 
but only segregated in order to prevent them from mixing with others. 
It is singular that the perverted in many cases strongly appeal to the 
sympathies of the physician. We have had occasion to be consulted in 
reference to sexual perversion by men of intelligence, who have under- 
stood the enormity of their actions, the consequences and the punish- 
ment they had to suffer, yet they were unable to control the impulse. 
Cases of perversion occur amongst all classes of society, but many 
cases are to be found among educated and intelligent people. 

Some of the perverted are epileptics, and during the epileptic 



4 o6 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

attacks commit obscene acts. Their act is a substitute of the epileptic 
fit. Kowalewski 48 noted that coitus has some resemblance to the 
epileptic attack from the tonic tension of the muscles, the loss of 
consciousness and the mydriasis. Moreover, the epileptic attacks are 
often accompanied by a strong inclination to coitus, and sometimes the 
first coitus starts the first epileptic attack. 

DaCosta 49 referred to a case of an intelligent epileptic who in the 
excitement of the attack masturbated himself with his own mouth, in 
a very unusual manner. In many cases epilepsy is not recognized, 
and it is only found out later, when attacks show up in their classical 
form. 

An Italian of good education told us that he could not satisfy his 
sexual instinct unless by means of pederasty. He was discovered, lost 
his position, and punished. He had tried coitus with a woman but 
once, and could not accomplish the act. He only found satisfaction 
in pederasty, which came in attacks at different periods. When he was 
under this impulse he left his position, could not work, and went around 
looking for a boy with whom, as he said, he had fallen in love. 

Although he showed no particular marks, yet the conformation 
of his head was not entirely normal. The skull, of the brachicephalic 
type, was rather small in the posterior part, while the frontal portion 
was elongated and protruding. It seemed that the development of the 
head was confined to the frontal organs at the expense of the posterior 
ones. This peculiar anomaly gave him so strange an appearance as 
to show that he did not belong to the ordinary class of men. 

Krafft-Ebing considers these brutal tendencies as an inversion of 
the sexual appetite. He considers as a condition of the same kind, 
the abnormal propulsion of platonic love or an ideal cultus for an 
individual of the same sex with aversion for the other sex. The 
psychical life is all given to this abnormal love, with susceptibility, 
jealousy and irresistible tendencies, just as in normal love. One clear 
case of the kind was that of Miss A. Mitchell of Tennessee, who 
killed her companion, Miss Freda Ward, with whom she was in love, 
for fear that she would marry. 

Crimes against decency find their psychiatric form in satyriasis 
and in nymphomania, which sometimes occur in the prodromal stage 
of general paralysis, of epilepsy, of senile dementia. In some cases 
these conditions may be induced in boys at the time of puberty by 
reading obscene literature, and more often by masturbation. This 
horrible and dangerous habit excites the phantasy, increases the sexual 
appetite, and on being gratified, exhausts the power of the ganglionic 

48 Kowalewski. Archiv. psichiatr. 1885. 

49 DaCosta. The Journal of Nervous Diseases, 1887. 



Plate XVI 




Francesco Gioli 



SYPHILIS IN RELATION TO DEGENERACY 



407 



centers, so much so that the patient loses all sexual pleasure and 
seeks to regain it in an unnatural way. It is a singular thing in the 
psychological manifestation of these patients, that they usually lose 
all moral feelings and yet express exalted sentiments and superiority 
to all men. 

In our study of this class of patients, we cannot fail to recognize 
in them some marks of moral insanity. In all the morally insane 
Krafft-Ebing found, as did Lombroso, in many born criminals a re- 
markable precocity for sexual appetite and sexual perversion, often 
followed by impotence. Their sexual instincts are precocious, un- 
natural, and in some cases are preceded or accompanied by cruelty and 
bloody ferocity. 

Here we meet with the most horrible crimes, which bear the name 
of Sadismus, from the Marquis De Sade, crimes which cannot be com- 
mitted unless by beastly delinquents and insane degenerates. The 
atrocious exploits of Jack the Ripper in the Whitechapel district in 
London have remained celebrated in the annals of criminology, the 
barbarous mutilation of the bodies of the wretched victims have caused 
a sense of horror in all the civilized world. Indeed, as he himself said, 
he was a mental monstrosity. 

France had her Jack the Ripper in the person of a Russian 
religious fanatic, who called himself the savior of lost souls. Nicholas 
Wassilyi began his mission by trying to rescue girls from ruin in the 
Quartier Mouffetard, but after he had been shocked in a love affair, he 
turned, as a Jack the Ripper, into an atrocious murderer. 

In Spain Garrajo in a certain time of the year enjoyed himself 
by drowning and cutting into pieces such women as he could get 
hold of. 

Vergeni in Italy in a single year tried to strangle seven women, 
two of them he cut to pieces. He used to keep their flesh, which he 
would boil, and then eat. He confessed that the holding of his victim 
by the neck, the biting her, and her struggle in the suffocation, pro- 
duced in him the greatest pleasure. The sufferings of his victim in- 
creased and exalted his strength to such a point that with a small 
pocket knife he could break the spinal column. 

Lombroso referred to the horrible case of Francesco Gioli, who 
killed and mutilated with a small pocket knife two little girls, one five 
and the other seven years old, after having raped them both. When 
arrested he confessed that he had violated the girls, and said that it had 
been for him a great pleasure. His photograph, reproduced from the 
Corner e Illustrato delta Domencia for May, 1903, shows plainly the 
characteristics of degeneracy and criminality, and both his parents 
had been syphilitic. 



4 o8 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The mental development of Gioli was so poor as to impress any 
observer with the idea that he could only cope with children, because 
he would have been afraid to attack a grown person. He had only 
twice in his life the satisfaction of his sexual appetite, and both times 
in this atrocious way. 

The special characteristics of these crimes when committed by 
the perverted are the mutilations and the bites found in the victim, 
who is not chosen for her beauty, but taken at any age, from the child 
to the old woman. Crimes of this kind are usually found in certain 
seasons of the year, such as winter and spring, and diminish in number 
in other seasons of the year. 

The criminals are usually young men, deviating from the normal 
anthropological type, with stigmata of degeneracy on their faces and 
heads. They have a peculiar, sad expression, which reveals the moral 
abnormality. They are usually the offspring of parents addicted to 
alcoholism or insane. In most of the cases their parents have suffered 
the ravages of syphilis, and they are simply heredo-syphilitics. They 
are morally insane, or epileptics, and their perversion and crimes are 
to be traced to the heredity syphilitic taint. In some cases they are 
imbeciles or idiots, deficient in mental qualities, as the result of the 
same abominal syphilitic heredity. 

In other cases perversion and degeneracy may also make their 
appearance in older persons. In these cases heredity "may have had no 
influence, but acquired syphilis with its toxic influence on the nervous 
centra, causing meningeal inflammation, may be at the bottom and 
explain the criminal perversion. 

The criminal perversion which may be the result of a syphilitic 
inflammatory process of the meninges, or of intoxication of the neuron 
from its toxins, may be brought to act only on the association with 
the use of alcohol, opium, cocaine, etc., which have so deleterious an 
effect on the psychical condition of an already unbalanced individual. 

Habitual malefactors, degenerates and the perverted have to be 
considered, as does Lombroso, as a class apart from the generality of 
men, as they indeed show different tendencies and different feelings. 
The acts performed by the delinquent are the only visible results of 
the functions performed by the brain and reflective nervous system 
and are abnormal because the nervous system is in an abnormal con- 
dition. The anthropological studies of the bodies of that class of men 
have revealed anomalies, dystrophies, abnormalities indicative of re- 
gression and of an arrested development. The skull has often been 
found small with some anomalies in the position, shape and closing of 
sutures. Irregularities of the face, in the bones of the nose, of the 



SYPHILIS IN RELATION TO DEGENERACY 409 

jaws, also exist, while anomalies of the convolutions of the brain have 
often been found in criminals, showing that they are physical as well 
as moral degenerates. 

Causes of disturbances of the action of the brain are to be found 
not only in the original development of the organs, but they may also 
be due to pathological conditions of the blood, of the blood vessels, 
membranes, bones, etc. 

In ten cases of dementia praecox 50 Pighini and Teoli found 
peculiar alterations in the blood corpuscles, especially in their hemo- 
globin. These alterations they maintained to be the result of toxic 
elements, which according to Kraeplin are produced by the development 
of the sexual organs. Indeed, the age of puberty has been found to 
be the age when crimes of violence are more often committed. It is 
a critical period, which is sometimes dangerous even for well-balanced 
minds. 

The affections in the degenerate are abnormal, so much so that 
he may assassinate his parents, and yet make great sacrifices for a 
companion in need. Sometimes they show exaggerated affections for 
lower animals, at other times they are cruel, thus showing inconsistency 
in their psychical functions. 

One criminal may commit a crime on account of the degraded 
anatomo-physiological conditions of his brain with reflection and not as 
impulsion due to the passion. Another, on the contrary, will, without 
reflection, wound or kill a man in the impetus of passion in consequence 
of an overwhelming stimulus. Both kinds of criminals, although dif- 
ferent in the action, yet merge into one another, and as Sergi asserts, 
the want of reflection shows an abnormal condition of the sensory 
organ. 

The multiplication of the defective, degenerate and criminal classes 
has become so prominent a feature in our modern civilization as to 
attract the attention of medical and juridical men and make them at- 
tempt to establish some measures for prophylaxis. These classes are 
not only a constant danger to the public, but they entail great expenses 
in the maintenance of public institutions. In the past, defective indi- 
viduals were left to the mercy of nature or to the maltreatment of the 
ignorant masses. Deficient men after all were not such a prominent 
feature in those times, when slower methods and less intense means 
were used in the struggle for life. For the insane and idiots there 
were no asylums, and they either died naturally in consequence of 
privations, or if they survived they were the fools of the towns. Crimes 
were not less frequent than at our times, but no telegraph wires or 
newspapers gave them the widespread notoriety of to-day. 

50 Pighini and Teoli. Rivista Sperim. cii Franejatria, Vol. xxxi. 1005. 



410 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The new school of criminology which was founded by Lombroso 
and confirmed and established by Sergi, Ferri and other illustrious 
Italians, has entirely diverted the attention of the old penologists from 
the crime to the criminal. This has changed the criminal law into a 
study of criminal sociology. 

They have cast aside the dictates of Beccaria and Howard to 
diminish the punishment only as a reaction against the severity of the 
medieval laws, taking as their principal object the diminution of the 
offenses by decreasing the number of the criminals. This can only 
be obtained by an accurate study of the criminal and of the social 
environment leading to crime. 

We cannot believe that prevention of marriages of the defective 
can be enacted as a law. Nobody can go against the laws of nature, 
and the impediment to marriage on account of moral deficiency or 
degeneracy will never diminish the degenerates. Nature itself finds 
its providential laws, and with the mixed marriages families are either 
extinguished, or their tendencies will by education be gradually 
changed. In the Journal of the American Medical Association 51 there 
has been advocated a special legislation against degeneracy. It is not 
consistent with the views and with knowledge of physicians, the pass- 
ing of resolutions to be calling for laws against degeneracy without 
studying the causes which most often produce degeneracy. 

We have already proposed to stop the spread of syphilis by pre- 
venting men infected with the disease when inoculable from receiving 
a license to marry. From our studies it has been clearly shown that 
one of the causes producing degeneracy, neuroses, psychoses, etc., 
which degrade the human race is syphilis, and against syphilis we must 
direct all means to diminish the spreading of the disease which causes 
degeneracy. 

In reference to the deficient, dependent, and more especially to 
perverted boys and girls who have already shown signs of depravity, 
the juvenile courts, which decide their commitment to some institution, 
are to-day a step in advance. Instruction and education, associated with 
a strong inflexible discipline, will do a great deal in bringing to the 
right path a large number of boys and girls who, left to themselves, 
would grow up as criminals to fill the penitentiaries and the brothels. 
There are many poor children who are not well developed in their 
mental qualities, who have miserable homes where they have seen 
nothing but quarrels between their parents, and heard nothing but 
blasphemous talking, and once in a while they show symptoms of the 
hereditary syphilitic taint. These poor creatures have never heard a 

B1 Journ. Am. Med. Assn. Editorial, Feb. 15, 1902. 



SYPHILIS IN RELATION TO DEGENERACY 411 

kind word addressed to them ; when sent to the public schools the 
teacher has never taken an interest in them and has tried to get rid 
of them, so they must continue in the inclination of their father and 
enter the career of the criminal. But when these children in destitute 
circumstances, with an improper home, are taken in well-directed 
institutions, reformatories, reform farms, houses of refuge, under the 
modern pedagogic rules, they will be educated until they can be 
released as good members of society. 



Ill 

SYPHILIS AND PUBLIC HEALTH 

It is an interesting question to determine whether syphilis has a 
tendency to shorten human life or not. We have already treated this 
subject in Chapter VII, " Individual Danger from Syphilis," and we 
have shown by statistical tables that death from syphilis is only of 
rare occurence. Yet in the consideration of various subjects connected 
with syphilis we have seen the tendency of this disease to affect the 
blood vessels, causing arteriosclerosis, with all the serious results con- 
nected with so universal an anatomical system upon which depends the 
nutrition of all tissues, and of all other systems of the organism. 

In the death reports syphilis but seldom appears, though it may 
often be at the bottom as the predisposing cause of death. When a 
physician is called to attend a case of apoplexy, or a case of paralysis, 
and the patient dies, the death report will be apoplexy or a stroke of 
paralysis. It would be risky and even indelicate towards the family 
to mention syphilis as a predisposing cause in the report of the death. 
It would be risky for the reason that syphilis is not the only cause 
of arteriosclerosis, but old age itself, the use of alcoholics, the quality 
of the food, sedentary habits, etc., may have some influence in the 
production- of the vasal disturbance. 

We have seen that aneurism of large blood vessels often has 
syphilis as its underlying cause, but we could not go on and state 
aneurism as the cause of death and syphilis as a predisposing cause. 
In many conditions of the heart, of the endocardium, syphilis may 
have been the cause, but yet we are not allowed to speak, and much 
less to write the dreaded name of syphilis. 

In hospitals we have seen cases of diseases of the liver go on 
record as cancer of the liver, and as interstitial hepatitis, and at the 
autopsy the liver was found studded with syphilitic gummata. 

In some cases diabetes has been attributed to syphilis, but yet 
nobodv would be justified in calling a case syphilitic diabetes. It 
would be risk)- when we consider that many other causes may have 
produced diabetes, and many other causes may have caused nephritis, 
and it may be that syphilis had no relation whatever to the disease in 
question. 

A number of affections have been called parasyphilitis because 

412 



SYPHILIS AND PUBLIC HEALTH 



413 



they may have had syphilis as a cause, and yet they are the result of 
a trophic process, which is not influenced at all by an antisyphilitic 
treatment. Even tabes and general paralysis, which we have seen to 
be the end of the syphilitic attack on the nervous centers, are con- 
sidered as parasyphilitic affections. Many neurologists object to the 
idea that tabes and general paralysis are always the consequence of 
syphilis, when they are the product of a degenerative process of the 
nerve cells, which may also be caused by other sclerotising processes. 

We find, therefore, that statistical reports are inadequate and 
cannot furnish us with true and positive data demonstrating death to 
be the result of syphilis. As an axiom we may state that in some cases 
syphilis abbreviates life. 

In a general way it cannot be stated that syphilis abbreviates life, 
because everyone has known and knows men at a ripe old age in 
splendid health, who in their younger days have had syphilis, and 
after a while they have been troubled with no more manifestations 
whatever. While we do not often have cases of individuals who, after 
having been infected with syphilis, have never regained their former 
health, yet they may soon show symptoms of tertiarism and die of 
other diseases, hastened by syphilis. 

Syphilis acts in different ways in the different individuals affected. 
We have seen that in the experimental inoculations with syphilis in 
the chimpanzee, not one of the infected animals survived over thirteen 
months after the infection. 

In man, of whom this disease seems to be a sad and an almost 
exclusive possession, the effects are not so severe, but in some cases 
either on account of a weak constitution, or on account of other 
diathesic conditions, or on account of habits debilitating the system, 
it causes so deep an impression as to ravage the whole organism, and 
gradually lead to death along with some other degenerative processes. 

Other diseases, too, show the same tendency to affect some indi- 
viduals in a benign form, and others in the most malignant and 
virulent way. In cases of small-pox, we see some cases showing only 
a few pustules and a very mild fever, while others will be affected with 
an hemorrhagic small-pox which will imperil life. In this matter we 
must think that the origin of the virus is not so much at fault, because 
from a very mild case of small-pox, or of syphilis, an individual can 
be infected and suffer a severe case of these affections, or vice versa 
from a case with a malignant tendency there may result a case with 
rather mild symptoms. As Hyde J said, instances of incoercible 
syphilis in the absence of all treatment, in the presence of even the 
best treatment, often indeed, before any treatment worthy of the name 

1 Hyde, J. N. "Syphilis as Related to the Problems of Longevity." Medi- 
cine, 1905. 



4 I4 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

can be instituted, pursue their disastrous career without let or hin- 
drance. The soil seems especially fitted for the multiplication and 
fructification of the germ. In these cases the skin is often riddled 
with half-formed scars and ulcers, the bones embossed with gummatous 
nodes, the arterioles plugged with obliterating new growths, and the 
viscera dangerously involved. It is a wonder that these wrecks of 
humanity survive with the mind in process of degeneration and the 
body often paralyzed. Yet certain of them are long in evidence, the 
shame of society and the reproach of the profession. 

It is not of much interest for us to examine cases of hereditary 
syphilis in their frightful mortality, or cases of early acquired syphilis 
in infancy. In a general way we can state that syphilis is acquired in 
the third decade of life, and it is more prevalent in large cities, while 
in rural districts cases of syphilis are rather rare. 

From the Census reports not much trustworthy information can 
be obtained on this delicate subject. In the Census report of 1900 for 
the United States, in the areas of registration and non-registration, 
1,039,094 persons died. For every 1,000, 109.9 died of some form of 
tuberculosis, and 32.9 of some variety of cancer or tumor. The total 
number of deaths from venereal diseases was 1591, of which 934 oc- 
curred in males, and 657 in females, thus giving a proportion of 
1.53 of deaths from venereal diseases. 

Indeed, it is difficult to understand the meaning of venereal dis- 
eases when we think that syphilis is only a part of this miserable 
family of diseases. Death may have occurred from other conditions 
related to venereal affections entirely different from syphilis. On the 
contrary, cases of visceral syphilis may have been reported as diseases 
of the different organs and the name syphilis may have been withheld. 
The uncertainty of such a calculation shows in itself the unreliability 
of these statisti.es. 

In reference to the mortality from the two diseases, which are 
considered as the result of syphilis of the nervous system, general 
paralysis and tabes, in the same census, 1900, there were registered 
947 males and 356 females who died of general paralysis, and 537 
males and 175 females who died of tabes, which in the statistics is 
given as locomotor ataxia. This gives a rate in each thousand of 1.8 
of males and 0.8 of females for general paralysis and 1.0 for males 
and 0.4 for females for tabes. 

These statistics show the already mentioned relative immunity 
of women against tabes, which, however, is only relative. Both sexes 
are subject to the dreaded diseases, only on account of the slighter 
amount of work of the nervous system tabes is not so frequent in 
women. 

If we take it for granted that all cases of death from general 



SYPHILIS AND PUBLIC HEALTH 415 

paralysis and from tabes, recognize syphilis for their sole cause, we 
have reason to assign to this disease 2015 deaths. In 1,039,094 deaths, 
2015 represents a little less than two per thousand, representing one- 
sixteenth of deaths occurring from cancer and tumors, and nearly 
one-fifty-fifth part of the deaths caused by tuberculosis. If all the 
deaths in the United States reported as due to venereal diseases were 
summed up with those coming from general paralysis and tabes as a 
result of syphilis, it would give a total of 3606, which is exceedingly 
small in comparison with 32,000 deaths from cancer and tumors, and 
109,750 from tuberculosis. 

Moreover, we have already seen that the largest number of deaths 
from syphilis occur in children affected with congenital lues, and 
also a few in young people before the fifteenth year of age as hereditary 
lues. All these cases of death do not enter into the conception of 
longevity when their life is smothered out in the very beginning of 
their development. 

• Although it is a difficult task to establish an approximate number 
of cases of syphilis on account of the patients trying to conceal their 
troubles, changing physicians, etc., yet as Hyde did, we too can form 
an idea from the annual reports of the American Dermatological 
Association. Their members, experts in the dermatological and syph- 
ilological science, have reported all cases coming under their observa- 
tion in the cities of Boston, New York, Philadelphia, Washington, 
Chicago, St. Louis, Cincinnati, Ann Arbor, Cleveland, San Francisco 
and Montreal, Canada. The total number of cases of syphilis observed 
in each year by so many specialists in such large cities, average be- 
tween two and three thousands, and this from the year 1878, when the 
reports began to be given, to the report of 1902, a total of 46,437 for 
syphilitic cases. 

Indeed, these reports are not given as general statistics, they rep- 
resent only the reports of a group of men, while many other luetic 
cases are observed and treated by general practitioners, and are not 
reported. Yet we must also admit that these specialists have cases of 
syphilis coming from a wider district than their own cities alone. 

Many populous cities of the United States are not included in the 
report of the American Dermatological Association, and every one of 
these cities must furnish a certain contingent to the number of the 
infected. The reports of the dispensaries and hospitals of the L T nited 
States Army and of the Marine Hospital Department give an average 
of 5000 cases of syphilis annually, which has to be included. Following 
the account of Hyde, we can calculate that in the whole United States 
100,000 cases of syphilis occur with a mortality of 2 per roo cases 
of the disease. 

If we study the statistical tables of the U. S. A. and the Marine 



416 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

Hospital given by Samuel Treat Armstrong, which we have already- 
had occasion to quote on page 146, we find that mortality from syphilis 
is much lower than 2 per 100 cases. 

UNITED STATES MARINE HOSPITAL SERVICE. 





Primary Syphilis. 


Secondary. 


Deaths 


1881 


284 


804 


8 


1882 


257 


677 


5 


1883 


197 


690 


11 


1884 


156 


650 


10 


1885 


135 


583 


9 


1886 


278 


626 


5 


1887 


405 


660 


7 


1888 


367 


805 


9 


1889 


299 


777 


10 


1890 


263 


809 


9 



MORTALITY OF MALES CAUSED FROM SYPHILIS IN ENGLAND. 



YEAR 



All Under 

ages 5 years 



881 
882 
883 
884 
885 
886 
887 
888 
889 
890 



1090 
1158 
1 180 
1174 
ii6t 
1 168 

1095 

984 

1069 

1049 



912 

994 
1024 
1020 

986 
ion 

920 

809 

877 
842 



5 10 



15 



20 ; 25 



35 45 ! 55 



65 



131 40 56 32 23 8 

12 42J 41 35; 15 6 

ii| 36J 42 32! 18 10 

n 37; 42, 30 15 7 

II 46J 38 32; 22 14 

9j 38! 41! 33i 25 5 

11 38 37 38! 25 1 14 

14 43! 42 36; 22 6 

9j 46 54; 35 27 12 

7, 40, 54 52 25; 9 



75 85 



11,137 



9,395 



32 24 



47 108 406 447 355 216 91 



MORTALITY OF FEMALES CAUSED BY SYPHILIS IN ENGLAND 



YEAR 



881 
882 
883 
884 
885 
886 
887 
888 
889 
890 



All 
ages 



998 
1069 

1 133 
1 106 

1035 

1063 

969 

943 

984 

1007 



10, 307 



Under 
5 years 



77i 
833 
932 
898 
827 
878 
786 
757 
776 
774 



232 



15 20 25 



3 21 



76 

IO 21; 58 

8 19 62 
4 19 49 

Q 20 60 



35 45 



2 


7: 


16 


47 


5 \ 


3 


15 5o 


4! 


8 


11 


52 


5 


3 


12 


69 


4 


2 


17 


62 


35 


62 


171 


585 



55 65 



56 30 29 

61 401 29 

54 35 TI 

54 42| 30I 3 
53 30 19 12 

55 27, 19! 8 

45 31 19 
42 33 21 11 

46 41 16 11 
65 42; 20 13 



53i35i;2i3 



86 



75 85 



1 1 
1 

2 
2 

3 

2 

4 
3 



18 1 



SYPHILIS AND PUBLIC HEALTH 417 

Although the statistical tables have a tendency to confirm the 
rarity of the cases of death from syphilis, yet they show that in a 
certain number of them syphilis, especially when acquired, directly 
or indirectly diminishes longevity. The statistical tables from the 
Army hospitals and from the Marine Hospital Service are taken from 
young men in the full vigor of life, who have acquired syphilis only 
recently, and the mortality in these conditions is surely one of rare 
occurrence. When we consider the statistical tables of men and women 
dying of syphilis in the United Kingdom, as referred to by Armstrong, 
we find it true that mortality from syphilis is low, because it scarcely 
reaches 2 in 100 cases. 

One interesting point is brought out in these tables, as it shows at 
wiiat age this disease is capable of causing death. That syphilis is a 
cause of great mortality among children is clearly shown by the tables 
given. The larger number of deaths in syphilitic children takes place 
under five years of age. After five years the number of deaths from 
syphilis diminishes, but gradually after the age of twenty-five it 
increases again until it reaches the maximum of mortality between 
the ages of thirty-five and forty-five. This age is just when the man 
has all the responsibility of the family, when his life is more precious 
for his wife and children. At this age the children rely on their 
father for support, for their education, and for the hopes of their 
future. 

We cannot and will not deny the possibility that many para- 
syphilitic affections may also be the consequence of causes other than 
syphilis, but we must accept, as everyone has to do, the fact that 
they are the sad end of lues on the nervous system. It is true that 
the age between thirty-five and forty-five is the period of life when 
business men are pressed by the rush of business, are struggling for 
success, and at times are also laboring under anxiety on account of 
illness or the loss of someone in the family. In some men, with the 
care of business there is also associated some amount of dissipation, 
abuse of alcoholics, tobacco, etc., which makes them a careworn wreck 
at the age of forty. 

If in a general way syphilis is not a determining cause in shorten- 
ing life, in a certain order of cases it plays, if not directly, indirectly 
the role of an additional cause for an early demise. Most of the 
cases of syphilis of the nervous system have affected men who have 
never had any idea that they have had syphilis, and consequently they 
have never taken any treatment. The time in which the severe nervous 
symptoms have occurred has* been ten and fifteen years after the 
infection. In many instances the symptoms have come at once, en- 
tirely unexpected after many years of excellent health. In one 



418 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

case the patient was affected with an obstinate deep ulcer of the base 
of the tongue, which had been diagnosed by several physicians as car- 
cinoma. It was a gumma which healed up easily under the mixed 
treatment. 

In one case the existence of syphilis had never been found out ; 
the patient could not recollect any time of infection, yet he had a 
form of glossitis hypertrophica, which gradually yielded to the use 
of mixed treatment. The tongue had returned to the normal condi- 
tion when he began to show a deep papular syphilitic form under the 
nails of the fingers and toes. A man of fifty with grown children 
began to complain of weakness in the left arm, and finally one morning 
he was no longer able to get up. He was hemiplegic, and died of 
apoplexy. 

Not long ago there came for consultation a man affected for three 
years with syphilitic amaurosis ; he had been totally blind ; he re- 
ferred to having had a case of gonorrhea, from which he recovered 
fifteen years ago. At the same time there was some phimosis, and he 
thought he had a little sore beneath the phimotic prepuce. A physi- 
cian treated him for gonorrhea, and although he called his attention 
to the possibility of a chancre under the prepuce, he assured him that 
there was no syphilitic infection. He recovered and forgot the occur- 
rence. Some five years after he married a young lady, who has always 
enjoyed good health, and does not show any luetic sign. In the be- 
ginning she had one miscarriage, and she has since given birth to two 
children in good health, who so far have never shown specific symp- 
toms. 

If we consult statistics from hospital and from dispensary practice 
we find that mortality from syphilis ranges from I to 2.3 per cent. 
Cases of primary syphilis which are usually tabulated as ulcers of 
the penis, vary from 3 to 5.2 per cent, of all other diseases, while cases 
of secondary syphilis vary from 12.1 to 15 per cent. 

It is necessary to note a certain variation in the reports between 
the number of cases occurring in hospital and in dispensary practice, 
so much so that primary syphilis among the hospital patients is 
rated at 1.94 and among the clinic patients at 1.58; for secondary 
syphilis in the hospital the average is 5.29, and in the clinics it 
is 7.77. 

It will be found of some interest to produce some statistical data 
from the department of the venereal diseases in the male and female 
wards in our service in the Hospital of Cincinnati, from 1890 to 
1902. 



SYPHILIS AND PUBLIC HEALTH 



419 







ON 

00 


ON 

00 


ON 

00 


CO 


ON 
00 


10 

on 

00 


VO 

ON 

00 


on 
00 


00 

00 


00 





ON 


! 

ON 



o\ 


3 


H 




2 

39 


2 

'28 
IO 


I 

I 

32 

10 

3 


4 

1 


3 

1 


5 
3 


5 
1 


2 


3 

1 
37 
4i 


I 

3 


I 


4 


2 


38 


Primary, with gonorrhea. . 










Secondary syphilis 

Secondary, with gonorrhea 
Secondary, with chancroids 


56 
8 


95 
9 

1 


43 
34 


33 
43 


36 
22 


53 
28 


91 

22 


124 

no 

I 


117 
32 


784 
369 
5 
3 
7 
8 




2 






1 












1 


2 

4 

12 

1 


1 










2 

2 

4 




1 


Secondary, with pregnancy 












1 
5 


4 


15 


7 


10 


11 


8 


6 


9 


98 
















1 






























1 

105 

4 

1 


1 

4i 

1 












Cong. & hered. syphilis. 


16 
5 


3 

75 

8 

5 


35 
10 

1 


5 

17 
5 
3 
2 


5 
52 

1 
7 


5 
95 

7 


1 
66 

9 
2 
1 


4 
44 

7 

1 


1 

88 

4 

6 

5 


256 

2 
I 

4 


140 
1 
2 

4 
2 


24 
1030 

57 

34 

14 

4 

9 

3 

47 

1 


Gonorrhea, with chancroids 


Gonorrhea, with ven. warts 












3 


2 






2 
1 

8 
































2 


1 


Syphilitic rheumatism .... 


1 
1 

1 

2 


2 


4 


6 


10 


6 


4 


5 






2 


1 
1 


1 




1 


1 
1 
1 














5 


Syphilitic pharynx 




1 










5 
4 
1 


1 


1 
2 


























Syphilitic stomatitis 

Syphilitic stricture, rectum 














1 










1 


4 


1 = 


1 


2 
2 
6 

1 












1 
ic 


1 
11 


'■*€ 


1 


1 
] 


1 
1 










7 
83 


Chancroids 


2 


; 


14 
1 


A 


Chancroids, with bubo 
Chancroids, with ven. warts 
Chancroidal ulceration. . . 
Bubo 


4 


] 
k 


[ . . . 
















) 1; 
5 2 


1 

> : 


I ■■ 

\ : 

1 . . 


( 

> : 




> : 

[ ] 


> ] 
[ . . 


c 

[ . / 








1 

r 

I ( 


23 
» 52 


c 


> ; 


Venereal warts 


> 24 








Total 


11 


7 16. 


M3 


[ 14: 


2 22 


122< 


318 


2 IQA TAz 


M4< 


m* 


*52< 


?32<< 


I 2768 











RESULT 





o\ 
00 


On 
CO 


ON 

00 


On 

CO 


*3- 

ON 

CO 


10 

ON 

00 


ON 

CO 


ON 

CO 

87 
84 

23 


00 

ON 

00 


ON 

ON 

00 


1 


1— 1 

8n 


1902 

Total 


Well 


49 

59 

9 


63 
78 
17 

6 


39 

87 

4 

1 


43 

80 

n 

8 


76. 

129 

14 

5 


135 

73 
n 

1 


61 

99 
21 

1 


49 
85 

TO 


43 
87 
16 

3 


14S 


2/10 


tt;> ttIs 


Improved 


78261 l87 T*87 


Unchanged 


21 

I 


28 ">"> 207 


Died 







3 


29 






Total 


117 


164 


131 


142 


224 


220 182 


194 IAA 


149 


?/|8 


529 


3-4 


276S 















420 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 



AGE 



Under i 

Between 1-5.. . 
" 5-io.. 

" 10-15- 

" 15-20. 

" 2030. 
30-40 

" 40-50. 

" 50-60. 

" 60-70. 

" 70-80. 



Unknown 



Total 



"7 



164 



131 



1 

1 

79 

104 

I5i 24J 16 
4 



10 vO 

on ; o 
x , 00 



71 
115 



142 224 



220 



182 



2 
I 

57 

106 

19 



194 



144 



o ' w 

o 

O 0> 



149 



2 6 
76jI40 

139 364 
14 



g, Total 



248 



529 



1 

3 

84 

207 

22 

5 
1 
1 



324 



18 

18 

9 

48 

865 

1481 

241 

72 

17 

9 



2768 



OCCUPATION 





00 


CO 


CM 

On 

CO 


CO 

X 


X 


10 MD 

CO 1 X 

1 


X 


X 
X 


X 







0> 




13 


H 


Actresses 














I 










2 




Artist 




















1 




3 


Bookkeeper 










I 












1 

1 

18 


Bookbinder 






I 

4 




















Cooks 




I 


I 
I 


I 




1 


I 
I 

2 


4 


I 


1 
2 


I 

1 
1 

38 
1 


3 

1 

49 

1 


Candymakers 




Clerks 














3 
4 
2 


Cigarmakers 
















Cloak maker 


























59 

1 


88 


50 


74 

1 


91 

2 


95 
3 


81 


77 


60 


53 


60 
1 


875 
9 


Dressmakers 


Factory hand <• . . 










Furrier 
















1 
34 














12 


13 


16 


or, 


31 


20 


35 


29 


19 


18 


31 


35 
1 

4 


313 


Journalist 




Laundresses 






I 




1 
1 
7 




1 




2 


2 


1 


12 


Milliner 






No occupation 


7 TT 


32 
4 


6 


8 


5 


2 


1 


6 


9 

1 


3 


4 




Nurses 




3 


8 


Peddlers 


3 












3 

i34o 

6 


Prostitutes 


29 ^8 IQ 


30 87 


87 W 


70 


46 


66 

1 


147 
1 

1 


444 


220 


Stenographers 




1 
1 
4 


2 




2 

1 




1 






1 
2 


2 


2 




6 












1 
1 
4 










2 






3 
























1 


1 




2 












1 


1 


9 
2 




1 


















1 
1 




I 




1 


2 




1 




6 




1 2 




4 
16 




2 

7 






3 


2 






1 


1 


4 

1 


3 




1 


2 






6 


























Total 


TT7 


t6/| 


T 3 T 


T/|2 


22/| 


??o 


t8? 


194 


T/f/I 


149 


248 


529 



























SYPHILIS AND PUBLIC HEALTH 
SOCIAL RELATION 



421 



Q\ o 



Married , 

Single . 
Widowed 
Unknown 

Total . . , 



29 

116 

19 



18 
101 

12 



34 

169 

20 

1 



70 

102 
10 



20 
117 



42 

190 

16 



94 
402 

32 

1 



59 

245 



5io 

2034 
17 216 

3! 8 



117 



164 



131 



142 



224 



182 



194 



i44 



[49 



248 



529 



324 



2768 



HOW BROUGHT 







ON 

00 


ON 

00 


CO 


rO 
Os 
00 


00 


10 

CO 


00 


On 

00 


00 

On 
00 


CO 





ON 


1 


O 

as 


3 


H 


Ambulance 


4 
4 


2 

5 


7 
7 


6 
11 


7 
28 


6 
18 


2 
8 


7 
17 


4 
15 


1 
23 


IO 

20 

I 

I 

53 


11 
25 

333 


9 
10 

205 
2 


76 

191 

1 


Cab 


Daughter 


Father 
















1 
6 






2 


Health Dept 
















597 
11 


House Refuge 










1 
2 




8 


Humane Society 






1 














3 
2 


Husband 








2 














Infirmary 
















1 










1 


Mavor 


1 






1 














3 

1 
20 


9 


5 
13 

177 

4 
06 


Mother 




1 
19 


1 

23 
2 

3 


1 
43 


3 
4 


3 

7 


3 

13 

2 

4 


Patrol 


2 


2 


7 


9 


19 




Police 










3 


8 


3 


2 


2 


1 


1 
88 


Sister . 










1 


Unknown 


106 


155 


109 


114 

1 

142 


164 


168 


133 


ti6 


115 


113 


141 


J 35 


1657 




1 










224 


220 


















Total 


117 


164 


131 


182 


194 


144 


149 


248 


529 


324 


2768 



The total number of venereal diseases treated in this long period 
has been 2768; the mortality has been 29, which is 1.02 per cent. In 
looking over the details of the result, we find among the cases of 
primary syphilis that one woman died of hydrosalpinx, which had 
nothing to do with syphilis. In the table of secondary syphilis we 
find that two died, both from Bright's disease. We are not, however, 
ready to state whether the nephritis had been the result of the syphilitic 
process or of some other cause, but we will not deny that syphilis may 
have been one of the determining causes. 

In the table of secondary syphilis with phthisis we find a total of 
seven patients, of which five died ; two left the hospital improved, one 
improved and one unchanged. We will not hesitate to say that syphilis 
has acted as a cause to render tuberculosis more deleterious, but it 
has not acted alone and no physician would report those five deaths 
as produced by syphilis, but by tuberculosis. 



422 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

Of the ninety-eight cases of tertiary syphilis, we find four were 
fatal owing to syphilitic cachexia, and one with tertiary syphilis was 
accompanied by mania and death came while this condition lasted. Of 
nine patients with cerebral syphilis, three died in the hospital, and one 
died of syphilitic meningitis. Twenty-four children were affected 
with congenital and hereditary syphilis, nine of whom have died as a 
consequence of syphilitic cachexia. One died with a phagedenic 
chancroidal bubo, which really could not be ascribed to syphilis. 

The age when the infection occurs and when the symptoms of 
the general infection are developed is entirely in accord with the sta- 
tistics referred to by others. 

The data for primary syphilis begins with 10 cases between the 
ages of fifteen and twenty, 25 cases between the ages of twenty to 
thirty, 2 cases between thirty and forty years of age, and 1 case be- 
tween forty and fifty, giving in all 38 cases. Primary syphilis with 
gonorrhea was found in 5 cases between the age of fifteen and twenty, 
and in 6 cases between twenty and thirty. Of the 784 cases of secon- 
dary syphilis, 3 occurred in the age between five and ten, 11 between 
the age of ten and fifteen, 254 between the age of fifteen and twenty, 
410 between twenty and thirty, 75 between thirty and forty ; 24 were 
found between forty and fifty, 5 between fifty and sixty, and 2 between 
sixty and seventy. 

The same age has given cases of secondary syphilis complicated 
with gonorrhea. Between the ages of fifteen and twenty, 115 cases, 
while 237 cases were found between the age of twenty and thirty, 12 
between the age of thirty and forty. Two w T ere found between the 
age of forty and fifty, 1 between fifty and sixty and 1 between the age 
of sixty and seventy. 

Of the 98 cases marked as tertiary syphilis 8 have been referred 
to an age between fifteen and twenty, which rather ought to be con- 
sidered as late hereditary lues. Thirty-five are between twenty and 
thirty, 33 between thirty and forty, 15 betAveen forty and fifty, 5 be- 
tween fifty and sixty, and 2 between sixty and seventy. 

One case of tertiary syphilis was reported associated with mania, 
at the age of thirty to forty. Xine cases of cerebral syphilis were ob- 
served, of which one occurred from hereditary lues, between fifteen 
and twenty, 4 between twenty and thirty, 1 between thirty and forty, 
2 between fifty and sixty. Three cases of syphilitic meningitis have 
occurred, one at an age between twenty and thirty, another between 
the age of thirty and forty, and one between fifty and sixty. 

From our statistics we obtain the same results, namely, that deaths 
from syphilis are very rare. In the City Hospital we have always our 
10,000 patients per year for all diseases. From 1890 to 1902 would 



SYPHILIS AND PUBLIC HEALTH 423 

give a total of 130,000 patients. Of this large number for all diseases, 
2768 were in the venereal wards for venereal diseases. This gives an 
average of 2.1 per cent, of venereal affections on the total of the 
common diseases. 

The mortality of 29 in 2768 is absolutely so slight, that as we 
have already stated in a general way, longevity is not much affected 
by syphilis. Unfortunately, syphilis with alcoholism tends to make 
poor and helpless wrecks, who often remain as a charge on the com- 
munities. 

Death from syphilis has occurred mostly between the ages of 
thirty and forty, but we have seen that death in several cases was not 
the result of syphilis alone, but was due to other infectious diseases 
in association with syphilis. 

The same statistical table also gives an idea of the social relations 
of our infected. At first glance it shows that men and women living 
single are more likely to acquire syphilis and venereal infections. In 
fact, of the 2768 cases, 2034 were in single persons, while 510 were 
in married and 216 in widowed people; the social relations of eight 
of them could not be ascertained. For this reason early marriages 
have to be recommended as a prophylactic means to avoid syphilis. 

It should be the duty of the parents to prompt their children to 
contract early marriages. It is a great mistake of the parents to 
prevent their children from getting married. It is better that the 
children learn the mysteries of the generative functions from their 
parents as a scientific teaching, than that they learn them from their 
companions as a mischievous and obscene enjoyment. Parents must 
remember that after the sixteenth year the idea of innocence is better 
" abroad " than at home, because their children will learn the things 
practically and will be in danger of infection. 

The table giving the occupation of the infected shows the larger 
number of infected to be the prostitute, in the number of 1340. It 
shows once more that prostitution is the hot-bed of syphilis and ven- 
ereal diseases. Second in the list are domestics with 875, and then 
housewives in the number of 313. One hundred and one could give 
no occupation, and usually those individuals who take anything to do 
without any permanent occupation, are very easily infected. 

Many other occupations give their contingent to the venereal 
diseases and to syphilis only in a moderate quantity. 

It will be found of some utility to have added a statistical table 
to show how these patients came to the hospital to be treated of their 
ailments. The largest number came of themselves without any urging 
from anybody, in the number of 1657. Five hundred and ninety-seven 
were sent from the Health Department compulsorily. One hundred 



424 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

and ninety-one came by themselves in cabs, and 76 were taken to the 
Hospital by the ambulance. One hundred and seventy-seven were 
brought in the police patrol wagon, and 26 were taken to the Hospital 
by policemen. Some were sent to the Hospital from other institutions, 
as from the House of Refuge and the Infirmary, some were accom- 
panied by their parents or relatives, and a few women were accom- 
panied by their husbands. 

The question of the Hospital for treating syphilitic patients is of 
the greatest interest, as it is intended to accomplish the greatest benefit 
to society, to remove the infected from the midst of the healthy people. 
The principal reason of the spreading of syphilis is that the infected 
remain free to mingle with others without any precaution. They do 
not think of the danger of infecting others, and as a consequence we 
see patients infected not only as a consequence of illicit acts, but also 
accidentally. From the table referred to we find that although many 
have applied willingly to the hospital for treatment, yet a great many 
ought to be sent compulsorily by the Health Department or by the 
police. 

We hear declarations concerning the necessity of maintaining 
personal liberty, that the dispensaries and the clinics are sufficient for 
the treatment of the venereal diseases, but we firmly believe in the 
necessity of receiving the infected in the hospital, where' they cannot 
have relation with others. The preaching of morality, and good ad- 
vice is all very well, but amounts to naught in this case if not accom- 
panied with a certain degree of coercion. In our hospital practice we 
also try to detain the men in the w^ard as long as they have secondary 
symptoms of any infectious nature. To keep in the hospital the pros- 
titutes when infected is of the greatest prophylactic importance, be- 
cause they are the principal cause of spreading syphilitic infection. 
In this regard we meet with another difficulty, which is that the hospital 
is an institution for the treatment of sick people, and not for trans- 
gressors who are affected with loathsome diseases on account of their 
indiscretions. Considering the question with respect to preventing 
infection, we meet with another difficulty; that a hospital is not an 
institution for public prophylaxis. 

In Italy it has been stated by Santoliquido 2 that the government 
has provided by instituting wards for syphilitic patients in different 
hospitals, the government paying the expenses of these wards. Of 
these wards there were 121, a number insufficient for the communities, 
which reach 8225. In order to place the institutions within the reach 
of everybody the government pays the expenses of the trip when this 

2 Santoliquido. "Institutions Hospitalieres." Compt. rend. Confer. Intern, 
pour la Prophylaxie de la Syphilis, etc. Bruxelles. 



SYPHILIS AND PUBLIC HEALTH 425 

is necessary. This has been done not so much for the individual in- 
fected as for the public welfare. 

When we consider syphilis a contagious disease, we must apply to 
it the same prophylactic rules which we apply for all transmittable 
diseases. The venereal diseases are highly contagious and therefore 
they must enter into this class of diseases. It is, therefore, necessary 
to find out the centers of infection and sterilize them so as to prevent 
their spreading. 

The number of patients treated for venereal diseases in the City 
Hospital is rather low and gives an idea of the number of those people 
who could not be treated in any other way, on account of lack of 
means or on account of the severe symptoms which compelled them to 
remain in bed. Santoliquido too remarked that the number of prosti- 
tutes registered in the public houses in Italy at that time, 1901, was 
5000, of which half had not been affected with venereal diseases in 
one year. Yet among all hospitals and dispensaries of the kingdom 
20,000 women and nearly 50,000 men had been treated for venereal 
affections. 

This is the only way in which the number of syphilitic infections 
can be made to diminish. The foci of infection have to be found and 
the infected have to be treated for their individual benefit, and at the 
same time must be placed in a condition in which they cannot spread 
the contagium. The work which is now in progress against tubercu- 
losis has to be undertaken against syphilis. It should be done in a 
way that would make the patient not attempt to hide his affliction, but 
on the contrary make him seek relief for it. Prostitution, which is 
the principal focus of syphilitic infection, has to come under surveil- 
lance, clandestine prostitution has to be looked after, and when those 
women are found infected with diseases of a contagious nature, they 
should be taken to a hospital and detained until any danger of infection 
has entirely passed. 

SYPHILIS AND LIFE INSURANCE 

Modern life has been greatly benefited by the most humanitarian 
of institutions, the life insurance. It is unselfish and has for its object 
the protection of the wife and children, who after the death of the 
husband and father would be without support. It entails self-denial 
and forethought on the part of the insured to meet his premiums, and 
this reacts advantageously on him and on his habits, engendering 
economy and the habit of saving. We can state that from the number 
of the insured, we can have an idea of the prosperity, honesty and 
uprightness of the community, as it is, according to Vanderpoel, 3 an 
3 Canada Medical Record. November, ■ 1S09. 



426 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

evidence of thrift, forethought and consideration of others, upon which 
social comfort and happiness chiefly depends. Life insurance is an 
American pride. It began as a small private institution in England, 
but has been developed through American energy into the greatest 
institution of the world. It has extended its great benefactions to 
all civilized society, and the whole world must greet and appreciate the 
blessing of this American enterprise. 

There comes up then for us the interesting question, whether a 
man who has had the misfortune of being infected with syphilis should 
be in any way prevented from enjoying the benefit of life insurance. In 
former times a man when found affected with syphilis was rejected 
as a dangerous subject, the risk for the insurance society being con- 
sidered too great. Gradually the medical examiners, inspired by the 
progress of the scientific treatment and by the results obtained, began 
to consider many questions in reference to the admissibility of some 
risk on the lives of persons who had been affected with syphilis. This 
study cleared the horizon of some of the clouds rolled up against the 
future of a syphilitic person, and we can say to-day that no objection 
is made against the admissibility to the benefits of the life insurance 
policy of a man who has had syphilis. 

We have seen from our statistics that deaths directly due to the 
disease are exceedingly rare in acquired syphilis, consequently syphilis 
in itself offers but a small risk. And as a matter of fact we have 
remarked cases of longevity in subjects who had suffered from severe 
cases of syphilis. 

Refusing insurance to a large number of insurable risks is a 
financial loss to the companies, and a painful disappointment to the 
applicants. This in a great number of persons once affected with 
syphilis can be safely spared, since we find in our daily experience 
that this disease in the ordinary cases, after a short duration of the 
early constitutional symptoms, dies out and only exceptionally shows 
up in the form of tertiary manifestations. 

To determine the degree of risk which a Company incurs in in- 
suring a person once affected with syphilis, it is necessary to take 
under consideration the constitution, the habits, and the treatment 
taken by the applicant. Medical directors are usually led to the 
acceptance of an applicant who has had syphilis, by this criterion : 
When the applicant, before being infected, has always enjoyed good 
health, and he is of a good physical constitution, it is an evidence that 
the morbid condition cannot have so deleterious an influence as in a 
weak and sickly individual. The nature of the case of syphilis has 
also to be taken under consideration, and so when the attack has been 
of a mild character, and no serious symptoms on the part of the organs 



SYPHILIS AND PUBLIC HEALTH 427 

have occurred, we can say that the attack of syphilis has been of a 
benignant type, and under ordinary circumstances it will disappear 
without relapsing. The successive relapses and their persistency make 
a questionable point as to the health of the applicant, and such appli- 
cants are usually rejected. But in the cases where no symptoms after 
the first eruptions have occurred for several years, no objection is 
made to insuring the applicant. The consideration, however, of the 
treatment undergone is another important question. We know that 
most of the cases showing tertiary symptoms are those which have 
had an insufficient treatment or none. It will be interesting to add 
a statistical table from Fournier 4 in reference to this subject. 

In a total of 1664 cases of syphilis he found 

Secondary syphilis of a benignant type 1424 

Secondary of a medium type 131 

Secondary intense and grave 45 

Tertiary forms 64 

1664 

This shows that tertiary manifestations can follow any kind of secon- 
dary syphilis, of a benignant as well as of a serious type. But not 
rarely tertiary symptoms occur after cases of very mild secondary 
symptoms, in the proportion of one to ten. Treatment of a heroic 
nature is that which in the greatest number of cases prevents and 
removes the danger of the ravages of the tertiary period of syphilis. 
In consequence, a consideration of the treatment undergone by the 
applicant is a good basis for the judgment of the risk which the 
society assumes in accepting a syphilitic applicant. 

The habits of the applicant have also to be taken under considera- 
tion. Alcoholism in these cases is out of the question, for if this is 
dangerous and risky by itself, it is much more so in association with 
syphilis. The habits of living, the excitement of a business life, the 
way of taking meals, the continuous mental strain, worry, these have 
to be considered all together, as all of them, in association with syphilis, 
may have dangerous results on the nervous system. 

Dr. H. Mireur 5 after considering the difference in the character 
of syphilis and the relation to the different individuals and to the treat- 
ment, concluded that there is no uniform line of procedure to be es- 
tablished by the insurance companies ; it is necessary for them to act 
according to the family and the personal history of the case and the 

4 " Traitement de la syphilis." Paris, p. 39. 

5 Marseilles Medicate, 1881. Quoted by Samuel Treat Armstrong. '* A 
System Gen. Urin. Diseases," etc. Vol. ii, p. 829. 



428 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

general condition of the applicant when examined. It is a rare ex- 
ception that the pernicious influence of the disease is not exercised 
upon the infected individual at the time it was acquired and the sta- 
tistics show that it has slight influence upon mortality. In this regard 
Sam Treat Armstrong refers to the experience of the companies with 
mortality from syphilis. He could obtain only from two companies 
positive data, but from all he had replies agreeing that the mortality 
caused by syphilis was extremely small. In one company in the large 
number of 22484 deaths, only five deaths had been caused by syphilis, 
while in another company, out of 10,952 deaths seven only were due 
to that disease, forming in all so small a percentage as to cause prac- 
tically very little risk. 

From the above considerations it results that the larger proportion 
of the American insurance companies have taken the same position as 
the European companies, accepting persons who have had syphilis, 
when they have been properly treated, and when they do not show 
any secondary or tertiary symptoms. 

We will refer to the opinion of some prominent medical examiners, 
who with their experience, confirm our views on this subject. Dr. 
Thomas Glover Lyon, Medical Officer of the Mutual Life Assurance 
Co., London, in reference to syphilis said that, " generally speaking, we 
should take anyone who has proved to have no symptoms, that is, in 
whom it can be reasonably expected that the disease is cured and in 
whom there was no reason to suppose the disease was not cured. If 
syphilis has had the ordinary mild course, and the symptoms ended 
some little time before two years' duration, a very short time after that 
two years we would take the applicant at ordinary rates. This is the 
general custom in England." 

Geo. W. Wells 5T on the same subject expresses himself in the 
following manner: " Syphilis is a disease which can be cured if taken 
in hand early, and persistently treated for a sufficient time. There 
does not seem to be any medication which will prevent the disease from 
reaching the secondary stage. While some cases of syphilis will ter- 
minate favorably without medicine, it is not safe to rely upon a spon- 
taneous cure. It is a fact that proper treatment will lessen the length 
of the secondary period and prevent the patient reaching the tertiary 
stage, or will cure the disease." 

He agrees with our observations, and says that " syphilis is not, 
however, such a formidable malady as it was thought to be in former 
times, because its malignancy has been proven less, and methods of 
treatment are improved so that, whereas in former times the subject of 
syphilis was little better than ostracized, to-day he is looked upon as 

6 The Medical Examiner, September, 1897. 



SYPHILIS AND PUBLIC HEALTH 



429 



having received but little harm, if any, by reason of his having had 
syphilis, provided he has undergone proper treatment for a sufficient 
length of time and leads a proper life subsequently." 

These conditions make possible the insurability of the applicants 
who have been infected with syphilis. There has been a time which 
we all remember, when an applicant who admitted having had syphilis 
was declined simply because he had had that disease. It was thought 
that the consequences were such that he could not be considered a 
proper risk under any consideration. A man once syphilitic was always 
syphilitic. This was the dictum, and for him there was no insurance. 

The point was taken from the period of life in which the tertiary 
symptoms appear, which is from five to fifteen years after the infection, 
manifesting themselves between the ages of thirty-five and forty years. 
At that time (after forty), the insurable age was considered too small. 
Moreover, there was to be considered the effect of the syphilitic virus 
on certain other diseases or diatheses, which are usually aggravated or 
made active by its presence. Tuberculosis, for instance, is made active 
in consequence of syphilis, and in the same way it has a tendency to 
arouse into activity gouty conditions, and by affecting the kidneys it 
may cause Bright's disease. 

Recently syphilologists began to study much more accurately the 
prognosis and the future of subjects who had been infected with 
syphilis. They showed statistics favorable to the infected — no bad 
effect upon longevity, — deaths from syphilis exceedingly rare, — cases 
of tertiary ravages nearly exceptional, so that medical directors began 
to change their mind in favor of insuring applicants who had once had 
syphilis, and a few years ago some companies began to accept this 
class of cases. 

We take from the article of Dr. Geo. Wells 7 the opinions of 
several medical examiners of foreign companies. Dr. Fr. B. Erman 
(Hamburg). The practice of insuring syphilitic persons may be 
safely followed in his opinion. European companies are very liberal, 
as they grant policies even for life rates and without extra charges in 
cases with syphilitic antecedents, provided three years have elapsed 
since syphilitic infection, and the general condition of the applicant i? 
good at the time of the examination. 

Most companies grant twenty-year endowments. This practice 
corresponds with the general opinion of European physicians, who hold 
that syphilis does not abridge life generally. Cases of syphilitic dis- 
eases of the nervous system, paralysis, atheroma of cerebral arteries, of 
the bones, liver and lungs are known to occur and destroy life : but 
these cases are rare, and they are apt to change the general impression 
that syphilis does not heavily influence the duration of life. The Gotha 

a. c. 



430 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

Insurance Company issues policies for the whole life, at ordinary rates 
to syphilitics, when three years have elapsed since the disappearance 
of syphilitic symptoms, and when the general health of the applicant is 
good. In general, German companies insure luetics, but try to diminish 
the risk of the supposed mortality by limiting the term of insurance. 

Not less interesting are the ideas expressed by Dr. Carl Herzcka, 
Budapest. Syphilis can be cured. When is it to be looked upon as 
cured? The possibility of a relapse does not warrant us to consider 
a man perfectly cured after the disappearance of all manifest symptoms. 
Calculated by such a disappearance a declaration of a cure is an 
arbitrary matter. This question cannot be answered in a general way ; 
collateral circumstances must be taken into consideration, and above all 
the gravity of the case, the duration of the manifest disease, the extent 
to which the affection is shared by the whole organism, and especially 
what organs are affected, whether relapses have appeared, whether 
sequelae of the disease can be discovered, what treatment was followed, 
how long it lasted, whether after treatments were employed. It is also 
important to examine the constitution of the applicant, his manner of 
life, and the state of health of his children. Then only the time since 
the disappearance of the last symptoms can be taken into consideration. 
with regard to whether the applicant can be considered as totally cured. 
Of course a cure before two or three years from the disappearance of 
manifest symptoms is out of the question. 

Dr. G. Ferrari (Genoa, Italy) says that to refuse insurance to 
persons who have at any time suffered from syphilis would be justified 
if syphilis were always an incurable disease, but we have abundant 
proof of its curability. He does not mean that all cases are curable, 
but he firmly believes that many infected persons, when well treated, 
and for a sufficient length of time, will remain healthy for life. In the 
prognosis of syphilis, great attention must be paid to the ground upon 
which the syphilitic virus falls. In people who abuse tobacco, alcohol, 
or who are subject to malaria, scrofula, obesity or diabetes, syphilis is 
very dangerous and will never be cured. Italians accept Fournier's 
opinion regarding the prognosis of syphilitics and syphilis. His per- 
sonal opinion is not to grant insurance to all persons who have been 
affected with syphilis, but only : first, to those who at the expiration of 
three years from the cessation of the disease, being thoroughly cured, 
have shown no symptom of syphilis ; second, to those who are of a very 
healthy constitution and live hygienically ; third, to those who stand the 
test of a most severe examination of every organ, or anatomical struc- 
ture, including an ophthalmoscopical examination. 

The opinion expressed by Dr. Edwards Ehlers of Copenhagen is 
also very favorable indeed. Syphilis has gradually lost much of its 



SYPHILIS AND PUBLIC HEALTH 431 

former intensity, because of a diminished inherited predisposition, and 
possibly also because it has lost part of its malignancy. A person who 
has gone through a regular course of mercurial treatment, after the 
first appearance of syphilis, and who lives regularly, can become as 
good a " life " as any non-syphilitic. The main cause for syphilis 
reaching its tertiary and dangerous stage is the lack of thorough treat- 
ment, or of defective treatment. The problem in insurance is to draw 
a line between syphilis which has been rationally treated, and syphilis 
which has had no treatment, or an incomplete one. A syphilitic appli- 
cant who has undergone a thorough and rational course of treatment is 
undoubtedly a more valuable risk than a person who has had pneumonia, 
pleurisy, typhlitis, and similar diseases. 

From the above considerations we see that syphilis in the ordinary 
cases, when the person is living a regular life, after a prolonged treat- 
ment, is not a disease capable of abridging life, and in consequence 
must not exclude an applicant from the benefit of life insurance. It is 
true that we have no positive signs to judge whether the person who 
had been infected with syphilis has perfectly recovered, but we have 
positive knowledge from cases of reinoculations that the person had 
recovered from syphilis. We have known a gentleman who died at the 
rioe age of ninety-seven, who in the twenties had passed through a 
severe case of syphilis with persistent relapses. 

Life insurance is business, and must be treated in a business-like 
way, without hypotheses and without poetry. Dr. Solomonsen 8 of 
Copenhagen, read a paper before the Second International Congress of 
Physicians of Insurance Companies, in Amsterdam, 1901, in which he 
expressed his views that even during the three or four years following 
the infection, and notwithstanding the absence of any suspicious 
symptoms, he believed that rejection was justified, because recurrences 
are most frequent in the first years. We do not see any reason for 
rejecting an applicant when he has no symptoms whatever, but simply 
because of the danger of recurrences. Life insurance does not insure 
against disease, but only life, and no harm would result to a life insur- 
ance company if a man insured three years after the infection, and with 
no present symptoms at all, should afterwards have a mucous patch on 
his tongue, or a papule on the palm of his hand. Solomonsen quotes 
Professor Runeberg, the chief medical adviser of the Kallon Company, 
who believes that all deaths due to cerebral softening, cardiac affections, 
sclerosis of the coronary arteries, are the result of syphilitic infection 
when they occur before the fiftieth year of life. In another article he 
maintained that limited arteriosclerosis recognized syphilis as a prin- 

8 " Syphilis and Life Insurance." The Medical Examiner and Practitioner, 
Oct., 1901. 



432 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

cipal factor. We can say with Fournier, " vous voyez la syphilis par 
tout,'' we can place syphilis as a remote cause of a long series of dis- 
eases, but we cannot prove that a case of apoplexy or of heart disease 
recognized syphilis as its cause. Syphilis has a great tendency to affect 
the blood vessels in their tunics in the form of arteritis ; in some cases 
it may even cause thrombosis of the capillaries, with disastrous con- 
sequences on the skin, nervous tissues, lungs, etc. These conditions 
are always found as a consequence of the tertiary stage of syphilis, 
which only rarely occurs, and then as a consequence of neglected treat- 
ment and of a debauched life. Dr. Bayet 9 of Brussels, on syphilis 
and life insurance, after considering the diseases and the other affec- 
tions as sequelae of tertiary syphilis, expressed the opinion that one 
ought to refuse : 

1. Any applicant showing signs of active secondary or tertiary 
syphilis. 

2. Any applicant who had had syphilis within three years. 

3. Syphilitic applicants who showed signs of intemperate habits. 

4. In some cases, syphilitics suffering from malaria. 

5. Syphilitics, who during the early stage, showed symptoms con- 
cerning the nervous system, as transitory paralysis, diplopia, epilepsy, 
apoplectiform deafness. 

In the cases of syphilitics who had undergone a proper course of 
treatment Bayet would admit them to a life policy on exactly the same 
conditions as those on which we allow them to marry. That they 
have been well and thoroughly treated for a couple of years, continu- 
ously at first, and then intermittently, and that for a year at least they 
have not shown signs of syphilis. 

In regard to the possibility of cerebral syphilis : When a 
syphilitic has been thoroughly treated, and for six years has presented 
no symptoms of any kind, he can be considered safe as far as cerebral 
affections may arise. In several of our cases where nervous symptoms 
have occurred the patient never knew he had ever had syphilis, and 
consequently had never taken any treatment. For this reason Bayet, 
in cases of syphilitics who had never had any treatment, would not 
accept their application unless for fifteen years after the infection, no 
syphilitic symptoms have made manifest the latent infection, and if no 
nervous symptoms have shown implications of these delicate organs. 
The treatment is thought to be sufficient after three years by Bayet, 
but, he adds, it is better if it has been continued for a longer time. 
In fact, he admits that the longer the treatment, the better he considers 
the life risk. 

9 Internat. Congress of Medical Officers of Life Ins. Com. at Brussels. 
Med. Examiner, Nov., 1899. 



SYPHILIS AND PUBLIC HEALTH 433 

T. B. Crosby in a discussion of " Some Extra Rating of Healthy 
Lives," which was presented by Dr. G. A. Heron of London, in refer- 
ence to syphilitics to be admitted into the insurance companies, said: 
" Our friend, Mr. Jonathan Hutchinson, who is a very great authority, 
said that he should only like to belong to a Syphilitic Life Assurance 
Society at ordinary rates. He stated that when a man has undergone 
a certain amount of treatment for three or four years, and shows no 
signs, enjoying a good state of health, he is pretty safe." 

On the other hand, we have hysterical writers, who see the shorten- 
ing of life from syphilis, and therefore establish circumstances and con- 
ditions in which companies can accept applicants who have been affected 
with lues. Bramwell 1G is of the opinion that syphilis shortens life at 
least by eighteen years, and he states that syphilitic applicants have to 
pay an extra premium. 

J. J. Graham Brown " after twenty years of practice as medical 
adviser of the Scottish Life Assurance Company, was called by the 
directors to formulate rules to be observed in the contracts demanded 
by men who have been infected with syphilis. He rejects all hospital 
observations in this matter as injudicious, because the patients with 
syphilis who go to the hospitals have more severe manifestations than 
those who apply for life insurance. Indeed, the applicants for life 
insurance belong to a social class- where the hygiene is better observed 
and the treatment is better followed. 

In reference to the risk concerning the assurance companies, the 
influence of syphilis on human longevity is not to be taken into con- 
sideration at the time of the secondary period. At this time the 
disease is never fatal, and usually no one comes up for application 
during the eruptive period. He recognizes that mortality is connected 
with the tertiary period mostly on account of late lesions in the cere- 
brospinal system as tabes, general paralysis, etc. 

It is of the greatest interest to know if the applicant has had a 
good regular treatment, and this is not easy to find out. 

Tertiary accidents appear from twelve to fifteen years after the 
infection, and as a general thesis the life of a syphilitic must be con- 
sidered always as shortened. Tertiary symptoms of a grave nature 
occur only rarely. Nine-tenths of individuals infected have to be 
considered as having recovered after the fifteenth year, but in one- 
tenth, serious disorders will undoubtedly result. For this reason Dr. 
Brown advises that a tax be imposed on those insured after infection, 
which should cease after the fifteenth year. 

10 Bramwell. " On Syphilis and Life Assurance." Edinburgh Med. Chirurg, 
Society. Ref. Brit. Med. Journ., Dec. 27, 1902. 

11 J. J. Graham Brown. "Syphilis and Life Insurance." The Scottish Med. 
and Surg. Journal, vol. xii, No. I, January, 1903. 



434 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

When a man has had secondary manifestations, and at the time 
of his application has no signs, there is very little possibility for the 
occurrence of tertiary accidents. An individual of good and strong 
constitution, who lives regularly, takes plenty of fresh air, will be less 
menaced than another who is weak, compelled to lead a sedentary life 
on account of his occupation, and in poor hygienic surroundings. 

When syphilis is contracted at an advanced age, the risk for a 
company is too great, and the expectancy is not considered bright. 
The idea that when the first syphilitic manifestations are mild, late 
symptoms are liable to appear of a severe character, is no longer 
tenable. All depends on the quality and the quantity of treatment. 
The patient would have been protected from the tertiary manifesta- 
tions if he had taken sufficient treatment. 

Brown insists on the quality of mercurial treatment at least for 
the first two years from the infection. Longevity depends on an early 
and vigorous treatment, and it is of vital importance for the assured 
as well as for the insurer. 

It must not be forgotten, however, that sometimes we find severe 
tertiary symptoms in individuals who have received and followed good 
and well-directed mercurial treatment. 

From these considerations Brown concludes that the syphilitic 
has not the normal longevity, and as a consequence he cannot be in- 
sured at the ordinary rate. In case of a man who has had syphilis, is 
in good health, is temperate in his habits, in whom the infection dates 
above four years, who for over a year has not seen any secondary 
symptom, and who has undergone a regular treatment, he will be 
accepted as a good life, but he must, if a man in the thirties, stand a 
light tax at least for five years, so as to cover the insuring society. 

If treatment has not been well followed, the tax should be some- 
what higher, as tertiary manifestations make life insurance a bad 
risk, no matter what extra tax is charged. 

In these cases of applicants who have been affected with syphilis, 
Brown advises that a blank be sent to the regular physician who has 
had charge of the treatment of the applicant. 

The blank ought to contain the following questions : 

i. When did X. consult you the first time in reference to the 
subject? 

2. Character and seat of the chancre, date of its appearance. 

3. Date of the onset and character of the secondary symptoms. 

4. Description of the treatment and time it was continued. 

5. How long has he not shown syphilitic manifestations? 

6. Has he shown anv tertiarv form? 



SYPHILIS AND PUBLIC HEALTH 435 



7. Does he drink liquors 



8, Has he any signs of tuberculosis, rheumatism or other con- 
stitutional disease? 

9. Do you believe him to be insurable, or do you think his premium 
ought to be increased with a tax, and how much? 

We cannot object to precaution in business matters, but yet look- 
ing to the statistics of mortality, which are so closely searched by 
assurance societies, the small rate of mortality from syphilis appears 
so clearly that they make of an applicant not only a " fair," but a 
" good " risk. Personal experience shows that syphilis when treated 
does not shorten longevity. From the medical studies it is plain that 
this disease, which has been so much dreaded, easily yields to the 
power of the mercurial preparations judiciously applied, so that we 
can justly claim that a man affected with syphilis can in a certain time 
be considered as cured. 

We think, therefore, that the Medical Directors for Insurance 
Societies have done well in removing from the examination blank the 
old question, whether the applicant has ever had chancre, gonorrhea or 
syphilis. 

If by chancre was meant a chancroid or soft chancre, everybody 
knows that it has no influence on the general health, that it remains 
as a local affection, which when healed leaves no consequences. The 
same can be said for gonorrhea, which, however, may remain latent 
as posterior urethritis or as gleet, having caused a stricture. In these 
cases it will be easy to recognize the condition from the appearance 
of the urine, as the urine will then be cloudy, show shreds of different 
kinds, and the microscope will reveal ^epithelial cells, lymphoid cor- 
puscles, pus cells, etc. 

In reference to syphilis, which is the most important point of our 
study, when in the secondary period the medical examiner can easily 
find out for himself with a careful examination of the skin, mucous 
membranes of the mouth and throat, and the lymphatic glands of the 
applicant. In looking at the general surface of the skin it is possible 
that some small papula or a pigmented spot, a syphilitic lesion, is still 
on the palms or on the soles. In a case where the first eruptions have 
entirely disappeared, the skin, which has been the seat of a macular 
or papular eruption, still shows a peculiar pigmented hue, which has 
been called cutis variegata. In women with thin and white skin. 
anomaly of pigmentation is greatly exaggerated in the neck as a form 
of syphilitic leucoderma or syphilis pigmentaria, which remains for 
years in the form of a yellowish or brownish discoloration. This light 
pigment staining is sometimes diffused, sometimes in the form of 



436 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

roundish patches, at other times in a reticulated form, but it is char- 
acteristic, so that when present it very rarely fails to disclose the pre- 
existence of syphilis. In men this peculiar appearance on the neck is 
not easily found, but on the chest, especially when remaining exposed 
in a cool room, cutis variegata is quite perceptible and its presence 
may give some hint for finding other symptoms of latent syphilis. 

The mucous membranes of the mouth and of the throat will in 
most of the cases show some erythema, in the form of a diffused 
redness on the ring of the palate, which does not cause any incon- 
venience to the patient, with the exception of some dryness, and in 
consequence the patient does not complain of it. This erythematous 
condition of the throat, syphilitic angina, lasts for a long time on 
account of its tendency to recurrence. Sometimes there are on the 
mucous membrane of the dorsum of the tongue, on the fauces and 
tonsils, limited infiltrated areas from the size of a lentil to that of a 
penny, which are nothing else than the repetition on the mucosa of 
the erythematous eruption on the skin. When we find such a con- 
dition of the mucous membranes of the mouth and palate, there is no 
difficulty in establishing the diagnosis of syphilis. The mucous patches 
on the mouth and throat are quite common during the first two years 
of the course of syphilis. They appear in the form of flat reddish 
elevations sharply defined, covered with grayish detritus. They are 
found on the mucosa of the lips, cheeks, tongue, especially at its 
borders, soft palate and faucial tonsils. On the tongue they are in 
the form of round, or oval, reddish patches scattered about the middle 
of its dorsal surface, or as whitish points at its edges. At the angle 
of the lips on the mucous membrane just where the two surfaces of 
the mucous membrane of the lips touch each other, small patches are 
found, which when present will reveal to the examiner the presence 
of an early syphilis. 

The examination of the lymphatic glands will in nearly all cases 
complete the diagnosis. It is true, that the lymphatic ganglia in some 
individuals are naturally enlarged, and it is also true that in some 
cases of syphilis very little engorgement of the glands takes place, 
but' yet it is one of the most constant symptoms and one which will 
reveal for a long time the course of syphilis. The lymphatic glands 
of the cervical, subaxillary, inguinal and epitrochlear regions are the 
most important to be examined. They are, as the result of the irri- 
tative process of syphilis, hard, the size of an almond or of a hazel-nut, 
movable, firm to the touch, and at times, when pressed with the finger, 
slightly tender. When syphilitic symptoms begin to disappear, then 
the glands slowly diminish in size, but yet for months and years they 
remain as the most evident sign of a past syphilitic infection. The 



SYPHILIS AND PUBLIC HEALTH 



437 



examiner, consequently, always will find the study of the lymphatic 
glands a great help to his diagnosis. 

In cases of late syphilis the examination is somewhat more com- 
plex, but with some care it will also succeed in ferreting out the 
presence of the disease. The scars of healed lesions will give an idea 
of the latent disease. In fact, the cicatrix which results from a syphil- 
itic infiltration, when of recent date, is surrounded with a copper- 
colored pigmentation, lasting for a long time. When old they are of 
a whitish and brilliant color. They are round and superficial, and 
when scattered on different places of the body they will stand as the 
witnesses of a rupioid eruption. Small round cicatrices disposed in 
a round area, in the vicinity of the nose, mouth, anus, or on the joints, 
will recall patches of multiple superficial gummata or otherwise called 
syphilis tuberculo-ulcerosa in a circinate form. Round, isolated scars, 
scattered on the legs, without an infiltrated condition of the surround- 
ing skin, are usually the result of multiple gumma. 

The mucous membrane of the mouth and throat often gives some 
help to the examiner in finding out a case of old syphilis. The pres- 
ence of leucokeratosis, a kind of milky white patches, consisting of a 
thickness and turbidity of the epithelium, covering the mucous mem- 
brane of the cheeks running back from the angle of the lips, towards 
the region of the molar teeth, and sometimes spread on the tongue also, 
is to be considered suspicious of pre-existing syphilis. In some cases 
the mucosa is only superficially thickened, of a white opaline color, 
and smooth, but in some other cases it is somewhat rough, hard and 
uneven to the touch. This condition, called leucokeratosis or leuco- 
plasia, has been found in persons who have never had syphilis, and 
this fact has led to great confusion. 

We do not wish to enter into so difficult a question ; we recognize 
the fact that some white patches may also appear on the mucosa of 
the mouth and of the tongue without syphilitic antecedents, probably 
only from smoking (plaques des fumeur of Buzenet), but we must never 
forget that syphilitics are predisposed to changes induced by smoking, 
and are more liable to show this condition of the mucous membrane 
of the mouth than others. When the mucous membrane of the mouth 
has been affected for a long time by persistent eruptions of mucous 
patches during the secondary period of syphilis, it is not entirely be- 
yond possibility to find that mucous membrane covered by a whitish 
hard thickened and imperfect epithelium. To this condition add the 
continuous irritation from smoking and chewing tobacco, and it will 
be easily seen that the presence of opaline plaques, of leucokeratosis, 
or leucoplasia, is oftener found in persons who have had syphilis, 
than in non-syphilitics. 



438 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The examination of the lymphatic glands will not in all cases, but 
certainly in some, reveal a latent syphilis. The cervical and the inguinal 
glands are the first to disappear during the course of syphilis, so that 
after three or four years the glands are scarcely perceptible. The 
epitrochlear and the subaxillary glands are usually felt in late stages 
of syphilis and the presence of these glands will call the attention of 
the examiner to syphilitic antecedents. The lymphatic glands, how- 
ever, once engorged and enlarged, cannot return to their normal size, 
and for many years they will remain perceptible to the fingers of an 
expert as small kernels. In fact, we have found in our own researches 
that the enlargement of the glands from syphilitic infection is not a 
genuine inflammatory one, but is due to an infiltrating process affecting 
the follicle of the gland, which produces a stasis of the lymphoid ele- 
ments into the cavitary system of the lymph glands, as a consequence, 
although the lymph returns to its normal course, yet the once infiltrated 
and engorged follicle of the gland will undergo a sclerotic process, 
causing a peculiar hardness, which remains hard for a long time, if 
not for life. 

In case of suspected tertiary syphilis an examination of the tibiae 
will often reveal a peculiar roughness of their anterior surface and 
especially of the crestse, which when present will tend to prove a 
pre-existent syphilitic periostitis. 

Any symptom which has any value for revealing an attack of 
syphilis on the nervous system has to be taken into serious considera- 
tion. An attack of facial paralysis, ptosis of one of the eyelids, are 
valuable signs to show that the nervous system is already affected by 
late syphilis. In these cases an ophthalmoscopic examination will be 
of great value in determining the condition of the fundus of the eye. 

We have already shown that the life of an applicant who has 
been affected with syphilis and has been well treated, after three years 
has to be considered not only a " fair but a good " risk. We cannot 
say the same for an applicant who has shown signs of tertiary symp- 
toms, and in our opinion it is more advisable to have him refused on 
account of the constant danger of serious visceral complications. That 
infiltration which in a limited surface under the skin we call gumma, 
may be formed in almost every organ or tissue, destroying their func- 
tion. The origin of the gumma is from the vascular system, and from 
it the bones, the joints, the nervous system, the liver, the kidneys, the 
lungs, and every part may be attacked with dangerous results. 

The companies recognize the importance of the scientific examina- 
tion, and they expect and demand continual watchfulness on the part 
of the examiner. They want a decisive reply, yes or no, and no recourse 
to explanatory notes. On the other hand, the examiner must be just 



SYPHILIS AND PUBLIC HEALTH 439 

towards the applicant, remembering that a hasty rejection of the latter 
may deprive him of the rights of life insurance. 

We are of the opinion that the examiner must not rely too much 
on the answers of the applicant, not because of any doubt about the 
veracity of his replies, but because in many instances he does not know 
much of the mild symptoms of the affection. When the examiner has 
found unmistakable signs of a recent syphilis, and he asks positively, 
" how long ago did you have the chancre? " the applicant cannot deny 
and will answer without hesitation. An applicant who has had syphilis 
three years before making his application, when he proves he has had 
a good and sufficient treatment, if for several months no syphilitic 
symptoms have appeared, if he is in good general health, and if he 
leads a regular and temperate life, can be accepted without much risk, 
as he can be considered as cured. The idea of imposing a tax on the 
life of a man who has had syphilis is a bit of red tape of the character 
of an unnecessary precaution. If it is true that nine-tenths of syphil- 
itics will never have any tertiary accidents, and only one-tenth will 
show severe symptoms, then we must say that insurance companies 
will undergo much more risk with any other insured than with syphil- 
itics. How many insured at thirty will turn alcoholics at fifty? how 
many in splendid health at the time of the insurance will be attacked 
by appendicitis or pneumonia a short time after having been insured? 
The imposing of a tax on the life of a young man in excellent health 
who four or five years before being insured had syphilis, for which he 
was regularly treated and has to be considered cured, is unjust, because 
the risk of the companies is not increased. 

When, however, an applicant has symptoms of old periostitis, has 
had forms of circinate syphilides, has shown gummata, caries, and is 
still under syphilitic infection, he has to be rejected as a dangerous 
risk. 

PUBLIC PROPHYLAXIS IN REGARD TO PROSTITUTION 

In the preceding chapters we have studied syphilis as a menacing 
scourge, and have affirmed that society must take steps to limit its 
ravages and to check its spread. Society has begun to wage a war 
against tuberculosis and leprosy with good results, and the same has 
to be done with syphilis. 

Syphilis as a social evil attracts international interest, not only 
on account of the sad results on the moral and physical condition of 
the individual, but also on account of the economical and material loss. 
forming a question of political economy. 

The object of public hygiene is to preserve the health of the people 



440 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

so that human life may be prolonged to its natural end. Every life 
represents a capital for the state and for society, which assume as a 
duty the preservation of this life in good health. A large number of 
individuals are rendered unable to work and so to earn their living on 
account of the ravages wrought on them by syphilis and other venereal 
diseases, so much so that many are not only of no value because un- 
productive, but they represent a constant expense to the communities 
as objects of public charity. 

In a general way we must state that the infection from syphilis 
and other venereal diseases is, in 90 per cent, of all cases, through 
sexual intercourse, while the other 10 per cent, is from extra-genital 
or accidental infection. The professions in some cases may be the 
cause of spreading of syphilitic infection. 

In the chapter on " modes of infection," we have mentioned acci- 
dental infection. We will only briefly recall the fact that cases of 
accidental infection occur quite often in our own profession, and when 
a physician has syphilitic lesions, such as mucous patches of the inter- 
digital region, it is his duty to be careful so as not to be a cause of 
contagion. 

In the brief statistical tables referred to under the head of profes- 
sions, the infected domestics were 875. This is a large number and is 
worthy of serious consideration. A cook or a dining room attendant 
affected with syphilis constitutes a continuous danger for the family 
that employs them. 

In our practice, over seven cases of initial lesions have been com- 
municated by barbers, especially through their practice of removing 
what they call wild hair. With the infected tweezers the barber has 
removed the hair from a healthy person, and the infection has been 
communicated. It would be of great advantage, and probably would 
save much suffering for the customers to demand that young barbers 
should be instructed as to dangers of infection and how to prevent it. 
If barbers were compelled to have a sterilizer with boiling water where 
they could place their instruments after using them, it would be a 
great benefit to humanity. 

It is always dangerous to employ men infected with syphilis in 
the factories, shops, etc., and let them mingle with healthy boys or 
girls. We had occasion to see three cases of hard chancre of the lips, 
which occurred in a glass factory, in three workmen, who received 
the disease from an infected companion through the glass blower. 

A musician lent his brass instrument to a friend of the same 
profession so as to enable him to earn some money. The instrument 
was returned. The musician did not think of cleansing the mouth- 
piece of the instrument and played on it. Some three weeks afterward 



SYPHILIS AND PUBLIC HEALTH 44I 

there appeared a chancre of the upper lip, which was followed by 
severe manifestations of syphilis. 

Although the accidental infections of syphilis are reckoned at 
10 per cent, of all syphilitic infections, yet the public has to be en- 
lightened upon this possible source of the evil. The glasses, cups, etc., 
in factories, in shops, in railroad cars, steamboats, have to be rinsed 
before applying them to the mouth. Table utensils, as forks, spoons, 
knives, which are left on the free lunch stands, and are used promiscu- 
ously by everybody, have to be looked upon with some suspicion, as 
they may become the cause of carrying infection. 

The unclean habit of promiscuous kissing has to be pointed out 
to the public as a possible cause of contagion and as an undesirable 
practice. 

Not very rarely have we had occasion to find in patients of both 
sexes hard chancres of the tongue, of the lips and of the tonsils, for 
which the patients could not give any possible explanation as to the 
infection, but it is clear that a kiss very likely had been the carrier 
of it. 

Illicit sexual relations, especially with prostitutes, are in most cases 
the means of syphilitic infection. Immorality and syphilis are the 
results of free prostitution. 

When a woman allows illicit sexual intercourse in consideration 
of money or other value, she is a prostitute. Before she reached the 
point of selling her honor and her body for money she was a woman. 
Unfortunately she loved a man, she was conquered by him, then she 
was betrayed in her affection, in her hopes, and she was left to her 
fate. This was the beginning of her downfall. That man should carry 
the blame, as he was the cause of the ruin of that poor girl. If that 
man had had respect for the gentle sex and had understood the re- 
sponsibility of sexual intercourse, he would not have acted so shame- 
fully and so cruelly. In the United States we have severe laws against 
such cases ; let the law be enforced and teach reform by its effect. 

Kromayer 12 believes that he finds the origin of prostitution in 
the disproportion of strength in the two sexes. The man with aggres- 
sive strength, in spite of the law, conquers the woman for the sake of 
satisfying his passions, and the woman on account of her natural weak- 
ness is unable to resist the sexual voluptuousness and concedes to his 
powerful aggression. These considerations may hold good for the 
woman who is betrayed, but for this reason only she is not a prostitute. 

The name of prostitute to be correctly applied requires a com- 
bination of circumstances, which debase and disgrace the unfortunate 

12 Kromayer, E. " Zur Austilgung der Syphilis." Berlin, 1898. 



442 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

creatures who fall into so abject a social condition. Yet a woman who 
abandons herself to dishonor, who gives herself to the first man she 
finds, is not a prostitute, she is a licentious woman, and from this 
tendency she may fall into prostitution. 

Parent du Chatelet 13 established the following circumstances as 
constituting the puella publico: recurrent relapses well established, pub- 
lic notoriety, arrest in the act of committing the crime proved by 
witnesses. This, however, limits too much the meaning of prostitution, 
separating the class of the debauched women, and circumscribing the 
prostitutes to those who have to be considered as belonging to the class 
of the perverted. Indeed, we have seen in another chapter that licen- 
tiousness and lewdness pass as a miserable heredity from the mother 
to her daughter. As a constant law of nature all living creatures 
resemble those who have produced them, and from one generation to 
another bad qualities of the body and of the mind are constantly 
transmitted. There occurs to us from our personal experience the 
idea that syphilis excites the nervous centers connected with the sexual 
activity, so as to make an affected person, whether the disease be 
acquired or hereditary, belong to the class of the degenerated and of 
the sexually perverted. 

The evil of prostitution, viewed either in reference to its effects 
upon the unfortunate females themselves or in reference to the ob- 
noxious influences upon society, is one of the most interesting socio- 
logical studies. When we consider the life of those unfortunate 
creatures, we find ourselves before an object deserving human sym- 
pathy. Everyone with a human heart, who has seen the lives of these 
women, especially the physician who has seen them suffering upon a 
bed of sickness and has heard the confidential outpourings of their 
soul, cannot do otherwise than feel pity and sympathy for them. A 
physician who has often witnessed their agony, who has seen them 
overwhelmed with the sense of the enormity of their guilt, despairing 
even of the mercy of God to forgive their transgressions, is capable of 
showing pity towards them, and of invoking from society means and 
reforms to succor them. 

The life of a prostitute can be compared to that of a butterfly, and 
it is interesting in every stage of her career, from the day she makes 
her debut on the public streets to the last hour when she closes her 
eyes in death. The same woman wTio has been decked in the dress of 
a peeress, is now in the rags of a beggar, without hope for anything 
better, with only a pill of morphine or a drink of whisky for her relief. 
But, as William Tait said, even in these unfavorable circumstances she 
is a woman and she still has the heart of a woman. If she, on account 

13 Parent du Chatelet. " De la prostitution dans la ville de Paris." 1857. 



SYPHILIS AND PUBLIC HEALTH 443 

of scandalous habits, on account of deleterious surroundings, has re- 
nounced society and its laws, let society take pity on her and prevent 
if possible her fall to the very bottom of the pit. We find very com- 
mendable the institution of St. Denis in Paris, where all prostitutes 
suffering from physical or mental infirmities, such as rectovaginal 
fistula, cancer, incurable organic disease, idiocy, are cared for while 
incapacitated from pursuing their calling. Only a few are sent to St, 
Denis in the course of a year, and the mortality, according to Parent- 
Du Chatelet 14 was not less than 25 per cent, per annum. 

Prostitution is a plague which can be considered coeval with 
society and is the greatest source of syphilis and it is against prostitu- 
tion that we must direct our efforts. The public does not care to know 
much about it and prefers ignorance on this subject. Of this social 
evil they usually speak in a whisper, and whoever tries to raise the 
veil to inquire into its mysteries, its origin, and its consequences, must 
meet with censure. 

It is, however, much better to know the exact dimensions of an 
evil than to keep it unknown and content ourselves with treating its 
frightful effects. Reticence is not a good policy. Public safety de- 
mands prophylactic measures to regulate the evil and prevent the 
spread of venereal- diseases. 

Vice in man, arising from a natural impulse, is the first origin of 
prostitution. Lack of education, laziness, idleness, together with the 
stern problem of living on the part of the woman, complete the work. 

It is absurd to believe that prostitution can be eradicated ; it is 
like any other evil of society which can be restricted, regulated, but 
will always exist. Physical punishments administered to men and 
women, the threat of future punishment after death, have never de- 
terred men from seeking and women from granting sinful pleasures. 
Guilty women have been banished, scourged, branded, and even exe- 
cuted ; their partners have been subjected to the same treatment, de- 
nounced publicly as immoral, divested of civil rights, and yet prostitu- 
tion has continued. 

The so much talked of teachings of morality and virtue have been 
powerless. In some cases amongst high-class and cultured individuals, 
it may restrain to a certain extent, but it will not have much power in 
the masses of the population. In the same way science has shown the 
sad effects resulting from venereal diseases on the man who is infected, 
and on his offspring, and yet even such terrible thoughts have not had 
influence enough to check the current. 

There remains, therefore, the only way to regulate prostitution 

14 Parent du Chatelet. Vol. ii, p. 273. 



444 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

and by restraining it under the strictest surveillance try to avoid the 
evil, which every civilized country has the right to combat. 

Prostitution is a kind of a trade, an industry ; the persons who are 
interested in this trade sell their bodies. On the other hand, it is a 
duty to see that the women are in a healthy condition, and that they do 
not constitute a danger for the community. The cure after the damage 
is done is a necessity, but the prevention is much better in order that 
we may prevent sufferings and financial losses to society. 

Ravages of syphilis can be checked by compelling public women 
to remain under strict surveillance. When one of these women is 
found infected with the initial lesion, she should be taken to hospital 
and treated for the chancre and then for the secondary symptoms. 
When free of symptoms she should be released. Meanwhile, she still 
remains under surveillance, and when a symptom reappears she is again 
confined to the hospital and the treatment is continued. 

In our personal experience we find this system of surveillance 
beneficial to the woman ; she has a regular treatment and is saved from 
the ravages of a neglected syphilis ; it is beneficial to society, for who 
knows how many young men would be infected by this woman dur- 
ing the condylomatous period, if she were left free to pursue her 
calling? 

When the houses of prostitution are under police surveillance, this 
is in itself a restraint against a great many showing themselves in those 
places, where they may lose their reputation. Minors will not be ad- 
mitted ; the admission of a boy in those places may be for him the 
poisoning of his mind and of his body, for in many cases a criminal 
career has begun with the first entrance into such dens. 

Surveillance may only succeed in obtaining a reform of a courtesan 
by giving a chance to good philanthropic people to show these people 
the enormity of their position. In a question of so vital an interest, 
which involves not only the welfare of the members of society, but also 
their descendants, every means which can check the spreading of syph- 
ilis and of venereal diseases has to be advocated. 

Legal Penalties for Prostitution. — It has been proposed to make 
any person legally responsible for damages who, knowing the danger 
of transmitting the disease, has sexual relations causing infection in 
the other party. This law should be founded upon the rule existing in 
nearly every country, that whoever causes bodily damage to another 
should be compelled to pay an indemnity for the expenses and losses 
caused to the other. 

Berenger 15 referred to cases where parents have been made re- 

15 Berenger, M. Conference Internationale pour la Prophylaxie de la 
Syphilis, etc. Bruxelles, Sept., 1902. 



SYPHILIS AND PUBLIC HEALTH 445 

sponsible for damages on account of the infection of the wet nurse, to 
whom they had entrusted their syphilitic child, fully knowing that it 
was capable of infecting. Court of Paris, January 10, 1884, and Novem- 
ber 27, 1896. 

In two other cases indemnities had been granted by the Court of 
Lyons against the directress of an employment bureau who had placed 
a syphilitic woman as wet nurse in a family, causing infection of the 
baby, January 14, 1858; and by the Court of Dijon against a physician 
who had not cautioned a wet nurse about the disease which she acquired 
by nursing the babe, and then communicated to her husband, March 
14, 1868. 

The same responsibility has been placed by the Court of Paris on 
the administration of public assistance, when on account of a neglected 
medical examination a child had been given to a woman to nurse, and 
she contracted syphilis from the contact of its lips. February 24, 

i8 93 . 

The penal responsibility would rest on three conditions: 1, attempt 
against morals ; 2, a train of suffering on account of infection ; 3, the 
knowledge of the possibility of contagion, as the points whereon to 
base the punishment. 

The transmission of venereal diseases would be made a crime either 
when it had occurred intentionally, or if it had occurred through volun- 
tary indiscretion. 

Some dispositions of a general order on crimes against the public 
health and on the transmission of venereal diseases have been enacted 
in Norway. M. Breda de Morgenstierne 16 of the University of Chris- 
tiania, referred to the penal law enacted in Norway May 22, 1902, by 
Bernard Getz. 

Whoever knowingly will expose to an imminent danger the life 
or the health of another shall be punished with reclusion to the extent 
of three years, or with imprisonment for three months ; in case of 
death the reclusion will be for five years, and the imprisonment for 
one year. If the culprit has spread disease knowingly for the purpose 
of gain, the court will add a fine, which can be increased to fs. 10.000. 

Whoever by his or her negligence has caused an attempt against 
the body's integrity or to the health of a person shall be punished with 
a fine of not more than fs. 1000. 

If the attempt is grave the court may sentence the culprit to 
prison rather than impose a fine. 

If the culprit has committed the offense while in the discharge of 
his functions, profession or industry, the court will punish him with 
imprisonment of not more than five years. 

16 Breda de Morgenstierne. Conference Internationale, ete. Bruxelles. tooj. 



446 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

If the negligence has been committed for the sake of gain, then 
the court will add a fine of not more than 5000 francs. 

In the law of Norway, and also of Switzerland, the transmission 
of syphilis is considered in different articles. 

In these articles are comprehended the transmission of syphilis in 
an extragenital way, the transmission of syphilis by marriage, and also 
the infection through the sexual act outside of marriage. In the last 
occurrence there are cases where the sexual act is punishable for but 
one of the two, as in the seduction of minors and attempts on children. 

With these dispositions of general law, a judge will not hesitate to 
imprison a man who under promise of marriage has seduced an inno- 
cent girl and has infected her with syphilis, or with another venereal 
disease. 

The penal responsibility, however, ceases when the disease is com- 
municated in the sexual act by the prostitute to her client. In this case 
there is a consent to the damage by the damaged party. 

If a captain of a vessel has accepted sailors whom he knows to be 
infected with a transmittable disease, it is also considered a crime 
against public safety. 

Whoever, knowing or presuming that he is affected with a con- 
tagious sexual disease, has infected or exposed to infection another 
person, either by sexual intercourse or by debauchery, shall be punished 
by five years' imprisonment. 

The same punishment shall be applied to anyone who shall have 
aided and abetted an individual, knowing or presuming him to be af- 
fected with a contagious sexual disease, to infect another person, or to 
expose her to infection under the stated circumstances. 

If one of a married couple suffers infection, or thinks he is exposed 
to contamination, then prosecution shall not take place unless by request 
of the first complainant. 

Art. 358 punishes anyone who employs a wet nurse for a syphilitic 
child. In the same way it punishes anyone who, affected with syphilis 
in the contagious stage, enters into a family as a domestic, or accepts 
the care of the children, and also him or her who knowingly employs a 
syphilitic person to nurse children. 

In the German penal law, Paragraph 327 says : 

" Whoever knowing himself to be affected with contagious sexual 
disease, shall have sexual intercourse with another person, shall be 
punished with reclusion for not more than one year, and a fine to the 
extent of 1000 marks. If the act is between man and wife, then prose- 
cution shall take place only on the complaint of the damaged party." 

This article met with great objections on account of other articles 



SYPHILIS AND PUBLIC HEALTH 447 

of penal dispositions against prostitutes, which concern the body's in- 
tegrity. Reichstag 8, Leg. II, 1892. 

In the Austrian penal code there is an article which says that 
anyone who knowing himself to be affected with a venereal or syphilitic 
disease shall have intercourse with another person, shall be punished 
with detention. In case of conjugal sexual intercourse, there shall be 
no judiciary prosecution. To the detention can also be added 
hard labor or any other more severe punishment, according to cir- 
cumstances. 

In the sense of the code actually in force in Austria, the fact of 
being infected with a venereal disease constitutes a grave circumstance 
for a person with the calling of prostitute. 

The penal code of Finland, chap. 20, par. 13, punishes with hard 
labor, or with detention to the extent of two years the contamination 
by sexual intercourse. The same dispositions are in the penal code of 
Denmark, par. 181, in the penal law of Schaffhouse, par. 185, and in 
Canton Ticino, art. 425. 

In the United States the law would reach the culprit, but it is 
difficult to find the damaged party in order to institute prosecution. 
In many States punishment is very severe in order to protect young 
girls from seduction and rape, so much so that in North Carolina it 
is a crime punishable with death. 

The responsibility of an infected individual who communicates the 
disease to another is in our States just the same as in the code of any 
other nation. Whoever produces an injury or in any way is the cause 
of suffering and of financial losses to another is responsible for, and is 
compelled to pay indemnity to the injured party, or suffer an adequate 
punishment. 

We have already stated on page 322 that in the United States the 
case of a husband who knowing himself to be affected with contagious 
disease infects his wife, is considered as a case of extreme cruelty and 
is a ground for divorce. This same disposition has been accepted in 
the penal code of many nations. It is a point of justice that this offense 
ought to be punished in the same way as if somebody by negligence has 
injured the body or the health of another party. In the case of rape of 
children, or minors, or other crimes of the kind, together with the penal 
responsibility for the rape, there is the contamination with the disease. 
A man who has not only seduced a woman, but has also ruined her 
health, must not be exempt from punishment. 

In many countries amongst the lowest classes of society there is 
still the superstition that coitus with a virgin is the remedy against 
syphilis. The law must punish severely such nefarious acts. 



448 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The social relations of the person infected with syphilis forms a 
great difference in the gravity of the occurrence. When a young man, 
single, contracts syphilis and behaves well, there will not be much 
danger of the spreading of contagion. But when a man who has con- 
tracted syphilis continues in his gay life, he may expose the health 
of others. In this case the penal responsibility can be considered as a 
just system of prophylaxis to prevent the spreading of venereal dis- 
eases. The idea of punishment might inspire fear, and contribute to 
check the spreading of the infection. 

The degree and the quality of punishment has to be left to the 
legislation of the different countries. One thing will always stand 
firm, that the offended person who has been subjected to financial 
losses has to be indemnified. If a man with syphilitic manifestations 
has seduced and infected a woman, this will cause her not only direct 
expenses but also inability to attend to her occupations. His act will 
be punishable not only as an attempt on the bodily integrity, but the 
law furthermore will authorize the woman to claim an indemnity for 
her financial losses. The circumstances will probably change the de- 
gree of responsibility when the infection has taken place without 
knowledge, or through grave negligence, as in extragenital infections, 
or also in the case of sexual infection in case of marriage. 

PROSTITUTION OF MINORS 

The law can reach this lamentable prostitution of minor girls ; the 
most dangerous element in the spread of venereal diseases. In general 
it is accepted in the majority of the States, that a girl who has not yet 
reached the age of twenty-one is a civil minor. 

E. Passez, 17 secretary of the committee for defending children 
brought to justice, said, that society has never taken so much interest 
in the protection of childhood as in our times, yet the evil does not 
diminish, but is rather on the increase, which is a sign of bad social 
conditions and of degradation of the young people. 

Minot 18 referred to the decennial reports of the Ministry of Justice 
in France, as showing an increase' of criminality at all ages, but es- 
pecially among minors. From statistical tables he concluded that 
juvenile criminality in France has advanced from 13 to 36 per 1000, 
more than double, and suicides among minors has increased from 15 
to 47 in one year. Criminality has increased among adults in the 
proportion of from 3 to 7. In 1841 in France 75444 were indicted, 
and in 1891 the number increased to 165,769. Suicides among adults 

17 Passez, E. " Rapports et vouex." 1890 to 1900. 

18 Minot, H. " Prostitution des minenres." Conf. Intern. Bntxelles, 1902. 



SYPHILIS AND PUBLIC HEALTH 449 

from 2700 in 1841 had increased in 1891 to the number of 8416, in 
the proportion of 9 to 28. 

The progression is much faster among the minors than among the 
adults. Statistical data show an increase of depravity amongst the 
young folks, and an increase of prostitution among the minor girls. 

Parent du Chatelet 19 relates that at the installation of the police 
des moeurs in Paris, the registration of the prostitutes commenced in 
1796, and a great number of girls were registered at the age of ten, 
twelve, fourteen, fifteen and sixteen years. Their youth was at that 
time no objection to their inscription, and the way in which those 
registers were kept shows that a much larger number of prostituted 
children were in Paris. 

In the archives he found many complaints sent to the administra- 
tion in reference to the scandalous way these girls acted, especially in 
the gardens of the Royal Palace. In these complaints there is men- 
tioned the great number and their extreme youth, their age being 
between twelve and thirteen years. 

Many more and even stronger complaints were sent in August, 
1804, and in the following year, asking the aid of the administration 
against the immense number of young prostitutes not registered be- 
tween the age of twelve and fourteen years. 

From the same registers there results that from 1816 to 1832, 
12,550 girls were inscribed as prostitutes, of whom 2043 were less than 
eighteen, and 6274 of the whole number had not completed their 
twenty-first year. Therefore, of 12,550 registered prostitutes, 8317, or 
two-thirds, were minors. 

From 1855 to 1869 in 6407 new registrations in Paris, according 
to Lecour, 20 4190 were of age, while 2217 were minors, and of these 
513 were under eighteen years of age. 

In the beginning the girls were registered as prostitutes without 
distinction of age, but after a while in consequence of serious com- 
plaints, the inscription has been refused to minors. It is true then, 
that lately the number of minors has diminished. This is shown by a 
Report of the Municipal Council of Paris. 



Year 


Of age 


Under age 


Total 


1872 


732 


280 


1,014 


1873 


643 


326 


969 


1874 


687 


326 


1,013 


1875 


641 


272 


9*3 


1876 


424 


190 


614 



19 Parent du Chatelet. L. c. 

20 Lecour. " La Prostitution a Paris et a Londres," 1872. 



45o 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 



Year 


Of age 


Under age 


Total 


1877 


398 


155 


553 


1878 


451 


173 


624 


1879 


259 


J 3 


272 


1880 


345 


9 


354 


1881 


390 


137 


527 


1882 


452 


42 


494 


1883 


485 


131 


616 


1884 


684 


322 


1,006 


1885 


890 


409 


1,299 


1886 


775 


37o 


i,i45 


1887 


592 


276 


868 


1888 


442 


265 


707 



In Marseilles, according to Mireur, 21 in a total of 3584 prostitutes 
inscribed from 1872 to 1881, 374 were minors, of which 104 were less 
than eighteen, 12 only fifteen, and one fourteen years old. 

Reports of other cities show that the proportion of the prostitu- 
tion of minors, which for some time constituted two-thirds, has now 
diminished to one-third, and these are not on the increase. 

The Central Committee of Statistics of the Ministry of the In- 
terior in Russia made an investigation of the prostitution in the Em- 
pire with the results that of a total of 17,603 prostitutes, 7840 were 
harbored in brothels and 9760 were free. Their age varied between 
fifteen and fifty-five years. Of the girls not yet fifteen years of age, 
14 girls were found in the brothels and 30 free. It was found that 
3040 girls in brothels and 2508 girls free had not yet reached twenty 
years, while 3272 girls in brothels and 3465 free were between twenty 
and twenty-five years of age. 22 

Although the statistics cannot be considered very exact, yet the 
investigation showed that 26 per cent, of all women in the brothels 
began their shameful career before twelve years of age, and 86 per 
cent, before attaining the legal age of twenty-one, while 25 per cent, 
began before sixteen years of age. 

In reference to the girls registered outside of the brothels, 50 
began their life of shame before the twelfth year of age, 1978 before 
sixteen years, and 7305, 75 per cent., when under twenty-one years of 
age. Consequently four-fifths of all prostitutes registered in Russia 
were minors when they entered the calling. 

In New York the juvenile degradation is clearly shown by the 

21 Mireur, H. " La prostitution a Marseille." 

22 " Statistique de l'Empire de Russie XIII." " La Prostitution a la date du 
1-13 aout." 1889. 



SYPHILIS AND PUBLIC HEALTH 45 1 

statistical tables taken from the answers given by those women who 
asked to be inscribed as prostitutes. Sanger 23 refers to 2000 prosti- 
tutes, of whom 750 were under the age of twenty, so much so that 
between the age of fifteen and twenty are found over one-third of the 
whole number of those belonging to this calling. 

The inscription of minors as prostitutes has always raised severe 
objections on the part of philanthropists. On the authority of Parent- 
DuChatelet it can be asserted that since 1836 one of the most serious 
questions for the administration of moeurs is to establish the age and 
the registration of minors. 

Public prostitution, however, is not all, but there is also the evil 
of clandestine prostitution, which offers many interesting points. 

According to Dr. Commenge, 24 chief of the dispensary of the 
prefecture of police in Paris, the arrests of minors made by the police 
des moeurs from 1878 to 1887 were 12,615, and those of the prostitutes 
of age, during the same period, were 14,392. 

From the report of Dr. Fiaux on the actual organization of the 
medical surveillance of prostitution, the arrests of minors from 1888 
to 1898 have been 14,072, and of those over twenty-one years of age 
14.736. 

From the comparison of these data it results that while in the 
period 1878 to 1887 minors arrested as clandestine prostitutes were 
46.7 per cent. ; during the period 1888 to 1898 they represented 48.8 
per cent., showing a small increase. 

Commenge remarked that young girls in the beginning of their 
career of shame are rather prudent and conceal their actions, so much 
so that the police have occasion to place them under arrest only many 
months, and even some years, after they have entered their calling. 
Indeed, the attention of the police is attracted only by their imprudence 
and eccentricities. As a consequence more adults than minors are 
placed under arrest. 

Jullien, at the conference of 1899, on his own statistics based on 
1000 diseased prostitutes under his service in Saint Lazare, showed 
that 3 of them had been initiated into debauchery between twelve and 
thirteen years of age, 6 at the age of fourteen, 8 at fifteen, 24 at sixteen, 
135 at seventeen, 146 at eighteen, 143 at nineteen, and 103 at twenty. 

Beginning with twenty-one years of age the proportion diminishes 
considerably. In this table, minor girls appear in the proportion of 
67 per cent. Fournier in his wide experience, declared that his ob- 
servations were in accordance with those of Jullien and Le Pileur, and 

23 Sanger, W. W. " The History of Prostitution," 1899. p. 452. 

24 Commenge, O. " La prostitution clandestine a Paris," 1897. 



452 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

maintained from his observations that the great majority of prostitutes 
began their vile practice before twenty years of age. 

Although we have not any exact statistical tables based on our 
experience, we believe that we are right in asserting that the largest 
number of prostitutes in our hospital service began their life of shame 
before twenty years of age. In their youth, led on by their sensual 
passion, they are very soon infected with syphilis and other venereal 
affections, and are one of the principal causes of the spread of syphilis. 
Moreover, when these young girls have been diseased, on account of 
their false fear of being detected, they remain a long time without 
treatment, and when they cannot stand on their feet any longer they 
will ask for medical attendance. 

CAUSES OF PROSTITUTION 

The insufficient moral education plays a great role in placing those 
poor girls on the downward slope. The inculcation of moral principles 
in both sexes must be the safeguard of society. The principles of 
morality rest on a just sentiment of indignation against any action 
which leads to indiscriminate sexual relations, and against all which 
tend to excite illicit sensual passion. 

The feeling of indignation against that which is immoral is 
acquired by education, or by inculcation, and makes us detest all that 
we judge to be bad and which ought not to be done. This sentiment 
of morality rests on the idea of a supreme law, which attaches hap- 
piness to virtue and punishment to crime. This sentiment also causes 
indignation against a criminal, who instead of punishment has had 
good luck, and causes admiration for virtue which remaining unknown 
has not been rewarded. In this sentiment rests the distinction between 
• good and evil, and makes us feel bound by an obligation in our own 
intelligence. In this is contained the principle of the natural harmony 
of virtue and of social happiness. 

Indeed, the idea of good and evil belongs to the order of truth, 
which morally does not admit demonstration. It is imposed on our 
intelligence, and with an absolute rigor appeals to our conscience. It- 
forms the law of our conduct, which we know as moral, or better as 
our duty. 

Everyone who has the idea of duty finds a moral satisfaction- 
connected with an act of virtue, and an internal joy when he has con- 
quered his passions. On the contrary, one who has fallen, who has 
violated the law of morality, and has succumbed to his passions, feels 
a secret mental suffering which comes from the conscience and is 
known as remorse. It is an agony, which can be considered as the 



SYPHILIS AND PUBLIC HEALTH 



453 



beginning of the expiation. This mental agony has often compelled 
criminals to denounce themselves so as to meet human justice. 

In the evasion of morality in our cases there are two motives, the 
satisfaction of lust and the venal gain. In the first they prefer pleasure 
to happiness, and sacrifice the future to the present. In the second, 
pleasure is reduced to calculation, the woman violates morality, sells 
her honor for the sake of money. 

The punishment is the direct consequence of their error, and the 
sexual diseases are often a severe punishment connected with the 
mental sufferings. 

In the human mind there is a natural wish for happiness which 
cannot be blotted out. The aim of the human mind is happiness, 
which in some exceptional cases on account of virtue may be denied. 
Hope, however, then takes place of the happiness denied, if it has not 
been consented to on account of virtue. But in general happiness and 
virtue are so intimately connected that they form an eternal harmony. 

The inculcation of religious principles, the idea of God as the 
only absolute infinite Good, the foundation of all human happiness, 
will elevate the morals of the young girls and strengthen their senti- 
ments with the idea of virtue, which is an emanation of God. The 
explanation and the inculcation of the duties of man toward ourselves, 
toward others, and toward God, will teach the foundations of morality. 

It is a natural law that man and woman must maintain their 
health and be developed according to the tendency of their nature. 
They must not obtund their sensibility, nor restrain their liberty, but 
all must be guided by their intelligence to keep the natural law. This 
will make them respect in others, and cause to have respected in them- 
selves, liberty, which is the principle of the morality of human actions. 
The social condition is the natural requisite of man and woman, who 
cannot live alone. This places upon man and woman the many duties 
of different orders of the social sphere, some concerning the family, 
some the nation, and others humanity. 

Social morality teaches to everyone respect for the rights of 
others, which means justice. The knowledge of God will maintain the 
morality of our children and the submission to his will will keep the 
generations moral. 

Another cause of prostitution is claimed to be laziness. The idea 
that woman has to be dependent on man is wrong. Man has to sup- 
port his family, but woman must not be entirely dependent and wait 
for the man to come and take charge of her. This was the condition 
of society in older times ; but to-day amongst enlightened nations woman 
has her employment and her occupations, so much so that she is no 
more dependent. In Europe, even amongst the working classes. 



454 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

woman works like man, yet the work of the woman does not receive 
equal compensation. Female employees generally receive smaller 
salaries. 

From recent accounts it appears that the women who are working 
for their existence are four and one-half millions in France, five to 
six millions in Germany, five millions in Italy, one million in Belgium, 
over five millions in the United Kingdom and nearly five millions in 
the United States. Work, whether of a manual or of an intellectual 
kind, has a moralizing influence on woman which makes her feel free 
and independent. The idea of earning her own money, of paying her 
own expenses, makes her careful and saving, and gives her the re- 
sponsibility which is proper for human dignity. This is well under- 
stood in our United States, where woman is introduced into so 
many occupations, just as man. Wherever work is sovereign there 
the people are free, there morality and happiness dwell together, the 
race is strong, industry is developed, public wealth is abundant. Lib- 
erty and prosperity are inseparable companions, and they are obtained 
only by work, which constitutes human dignity. Jules Simon said 
that when a town builds factories there working people are abundant, 
and when a town distributes charities then beggars take their place. 
Liberty, work and prosperity are absolute companions and are so for 
everybody, for every family and for every nation. 

The female workers, however, have to struggle not only with 
the competition among themselves to obtain work which is of ex- 
clusive pertinence to woman, but also against men who are opposed 
to seeing women placed in industrial establishments. Male workmen 
object to female employees for fear that female work may have the 
effect of diminishing their wages. Another serious objection to female 
work is that woman while engaged in work cannot attend to her 
duties in the family. This is true to a certain extent, because not 
onlv girls and single women take up occupations in factories and 
shops, but married women also in order to try to increase the resources 
for the support of their children. 

In families with means the girls are usually given a fine education, 
and the boys after finishing their college term usually go out to enjoy 
Ufe. In many of these cases marriage is considered a simple con- 
ventional affair. The family is often disrupted, corruption sets in, 
and the children grow up good for nothing. 

The working girl when she finds her earnings insufficient, looks 
upon male protection as a necessity, and marriage is considered by 
them as a kind of refuge. Marriage, however, is regarded by young 
men with growing repulsion. Their idea is to shake off the respon- 



SYPHILIS AND PUBLIC HEALTH 455 

sibility of the family, and their ideal life is the satisfaction of the 
brutal appetites. 

This condition of affairs makes it difficult for many girls to find 
a legal union, while on the other hand they are the object of solicitation 
by the man. Not all have a strong will to resist these suggestions, and 
thus many unwillingly accede to them, accepting concubinage in the 
hope of succeeding through fidelity and tenderness in having their 
situation legalized. L T nfortunately after some time just the reverse 
happens, they are forsaken, either because they have become mothers, 
or because they have aroused the dislike of their paramour. 

In this way poor women who would have been good mothers are 
by degrees led to prostitution. In the manufacturing cities of Europe 
young men after having lived with a woman for a while, abandon her 
and their children, and leave town to go to live with some other woman 
whom they will after a while abandon in the same way. These poor 
women, without support, easily accede to the suggestions of the first 
man who shows interest in their position, so they have a new lover 
and let themselves be carried down with the stream. 

The young men, on the other hand, imbued with the idea of delay- 
ing as much as possible their marriage, do not abstain from sexual 
relations, but from adolescence have learned to enjoy life, and as they 
say, make mashes. They boast among their companions of the num- 
ber of their good fortunes, without a thought that a seduction, followed 
by abandonment, makes a victim. Returning to the high social classes 
who can afford to send their girls to boarding schools, they find there 
only frivolous and insufficient education. All the sentiments developed 
are those of looking beautiful, the idea of the foyer, egotism, caprice, 
vanity. Nothing is substituted for a strong moral education, all is 
done for pleasure, and the girls are not prepared for the struggle of life 
in case of a reverse of fortune. 

In the working classes, unfortunately, very little is done to fortify 
their moral sense. Children are left in the street by their parents, to 
run all sorts of risks, where in company of larger boys, they learn 
things which ought not to be learned. Life in the tenement houses is 
another source of danger ; there parents and children live together, 
girls and boys find themselves in contact, often modesty is absent, and 
the imagination is polluted. In some families, unfortunately, drunken- 
ness and libertinage are found, either the father or the mother or both 
set a bad example to their children, and so the evil is multiplied. 

From the reports of the Juvenile Court of Cincinnati, in nearly 
every case of delinquent or of dependent children, the father was found 
to be a drunkard and the mother of questionable character. 



456 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

In England there have been recognized as one of the causes of 
physical and moral detonation the overcrowding of population, bad 
air, unhealthful conditions of work, alcoholism, a tendency to leave 
rural districts and crowd into the cities, bad and insufficient food, 
parental ignorance and neglect of children. Children are quite often 
underfed and they are morally and physically badly developed. They 
cannot study and compete with others in the schools who are well 
nourished, they are a trouble to the teachers, and receive no benefit 
from the imparted instruction. 

In the shops and in the factories there is the same promiscuity 
which is lamented in tenement houses. The girl does not find there a 
place to fortify her moral sense, but she is constantly in danger on 
account of continuous temptations and easy occasions. They have 
occasion to see other companions better dressed, another displaying a 
gold watch which she has received from her fellow, and they have the 
desire to imitate the others so as to obtain better dresses or a gold 
watch. 

Cheap literature with alluring titles is easy to obtain. Some go 
to the beer house, to the balls, to the concert hall, and the others, too, 
want to go and have a good time. There they hear immodest songs, 
interpreted with doubtful and suggestive gestures, amid the applause 
of the public, and these poison and pervert the imagination of the 
young girls. 

Under these circumstances it is necessary to admire and con- 
gratulate those girls who remain virtuous in so difficult and hard a 
struggle for life. The greatest danger of the working girls comes 
mostly from their workingmen companions, who in seduction see only a 
simple matter of pleasure. In this class of society, where the instruc- 
tion is only rudimentary, the education nil, morality a simple conven- 
tionality, where the necessity of earning their living affords them great 
liberty, the virtue of woman runs a great risk. 

PROXENETISM AND PROCURESSES 

These pests of society use innumerable arts to attract poor, in- 
experienced girls into their nets and give them as victims to the 
infamous Minotaur. They are in attendance at every public place, rail- 
road depots, landings, wharves, public parks, coach offices. They pre- 
sent themselves as old respectable ladies to entrap innocent girls. On 
some occasions a respectable-looking woman shows herself interested 
in industrial work and offers a situation to girls, who, when allured, 
are introduced to her male customers. At other times the procuress 
is disguised as a mother of the family, who allows some free relations 
of her son with the girl. In some cases they advertise in the news- 



SYPHILIS AND PUBLIC HEALTH 457 

papers to solicit girls for easy work at a good salary. Their purpose 
is to sell the newly acquired girl to her regular customers at a private 
sale, and when the first gloss is worn off, they cast them on the public 
market. It would take long to refer to all the different ways employed 
by those go-betweens in order to allure poor girls and make of them 
white slaves. There is no doubt that prostitution has been in the 
past, and is at the present, the result of the pretension of the man 
who wants to have the pleasure of life without the responsibility. He 
wants to enjoy. This is the preoccupation of that man. It is a brutal 
tendency, which has ruined the most precious lives. 

If we admit that woman is dependent upon man in a financial way, 
she is also dependent upon him from the sexual point of view. 
Renaud 25 wrote that woman seems to have been created essentially to 
satisfy the genesic needs of the male, and this is the predominant idea 
in marriage. For this reason woman in many cases tries to develop 
as much as possible the art of pleasing, of increasing her power to look 
beautiful so as soon to find a husband to support her in the struggle 
for life. 

Fallot said that anyone who asks a prostitute how it happened that 
she began her nefarious calling, will receive as a reply that she began 
her life as most of the girls do. Never did anybody tell them of the 
shame towards which they were going. An accident occurred in her 
life, an injustice which she thought she had received from her parents. 
or from a so-called friend, she was over-powered and everything, all 
good ideas, changed in her life. The same ideas were expressed by 
Commenge. 26 He does not believe that the simple sexual satisfaction 
and the need to have sexual intercourse with the man are the true 
causes of prostitution. We have asked this question of thousands of 
women, and only a very small number have admitted to having been led 
to prostitution through the generative passion which they needed to 
satisfy. 

Parent du Chatelet said that many girls are drifted to prostitution 
as a consequence of the loss of shame, which they could not explain 
and which can be considered as a mental alteration, which greatly 
diminishes their guilt in the eyes of the sociologist who studies their 
condition. 

Everyone who has had any occasion to study the life of the 
prostitute finds that in allowing the sexual act she does not consider 
it as pleasure, but as work. They are practicing a profession which 
has no attraction for them; it is. repulsive, but they continue in the 
trade for the simple reason that it gives them the prospect of gain 

25 Renaud, Joseph. " La faillite du manage et l'union future." 

26 Commenge. " La prostitution clandestine a Paris." 



458 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

in a less troublesome and hard way than if they should make their 
living by working. 

In prostitution, as in any other business, there is the offer and the 
demand. When men try to avoid married life, they try to satisfy their 
sexual instinct with ephemeral relations. That is what makes prostitu- 
tion a nourishing business. 

Although we are in favor of a strict surveillance of prostitution 
from a sanitary point of view, yet we cannot disagree with others on 
the moral point of view, that licensing prostitution makes it considered 
as a necessary business in social life. Men in general are persuaded 
that by physiological laws they must satisfy their sexual activity just 
as they have to satisfy their hunger. Many married men are so 
imbued with this idea that in case of pregnancy or of illness of their 
wife, they resort to prostitution, fearing to remain in forced continence. 

Many young men find themselves weak in generative power on 
account of the sexual excesses and the diseases which they have con- 
tracted in their adolescence. 

Minot 27 severely criticises physicians who in this regard are not 
entirely strangers to the upholding of these shameful ideas amongst 
young men. Many physicians teach that chastity is harmful to the 
general health of young men, and often advise adolescents to have 
regular intercourse with women. 

The demand, therefore, is always on the increase and procuresses 
are mostly looking for very young girls, who are much more in 
demand, and also more easily caught. 

The explanation of this demand in reference to very young girls 
we leave to Augagneur. 28 The man who is on the lookout for good 
luck, craving ideals, whatever they may be in his conception, looks for 
a woman who does not belong to the vulgar prostitutes. If he cannot 
obtain anything outside of prostitution, he will then go among pros- 
titutes, and will always choose one who is very young. This is not 
only because the young girl is more inviting, but also on account of a 
sort of poetry which still remains in the beginner, and is entirely lost 
in the older prostitute. 

The more dissolute and older a man grows, the more attraction 
he finds in the young girl. Ambroise Tardieu, 29 in reference to at- 
tempts to rape, remarked that the age of the criminals is in an inverse 
proportion to the age of the victims. Old criminals, in the lubricity 
of their lewdness, make children or adolescents the victims of their 
dissoluteness. 

27 Minot, H. "Prostitution des mineures." Conf. Intern. Bruxelles, 1902. 

28 Augagneur. " La prostitution des filles mineurs." 

29 Tardieu, A. " Etude medico-legale sur les attentats aux mceurs." 



SYPHILIS AND PUBLIC HEALTH 459 

Minor girls are more easily taken. The usual education they 
receive is not a sufficient safeguard from these dangers. An adult 
woman who has experience knows the consequence of the act, can 
understand the difference of the social situation, is less feeble, less 
impressionable, and is able to resist seduction. 

SANITARY CONSEQUENCES 

The same reasons which carry minor girls to their ruin, soon 
make them the victims of venereal diseases. They are exposed to 
these diseases on account of their tender age, inexperience, carelessness 
and the multiplicity of sexual contacts with the first man they meet. 
In the same way, when diseased, they spread the diseases without any 
restriction. 

Commenge gave an accurate list of the affections which were 
found in minor girls arrested in Paris, between the period 1878 to 1887. 





MINORS 






VENEREAL 




YEAR 


ARRESTED 


DISEASED 


SYPHILIS 


AFFECTIONS 


SCABIES 


1878 


1200 


438 


189 


269 


16 


1879 


1086 


394 


246 


157 


26 


1880 


1792 


614 


428 


242 


50 


l88l 


IIII 


476 


295 


176 


41 


1882 


140 1 


581 


386 


202 


52 


1883 


1449 


479 


301 


176 


35 ■ 


1884 


1391 


438 


265 


184 


19 


1885 


1232 


487 


227 


280 


19 


1886 


1065 


416 


172 


237 


32 


1887 


888 


389 


142 


246 


26 



Total 12,615 4712 2651 2169 316 

This table, although old, clearly shows that in the period of ten 
years, 1878 to 1887, 12,615 girls of an age between twelve and twenty- 
one were arrested in Paris on the charge of prostitution. Four 
thousand seven hundred and twelve of these girls had been found dis- 
eased, and 2651 were affected with syphilis, 56.26 per cent.; 2169 had 
other venereal affections, and 316 were affected with scabies. 

During the same period 14,392 girls over twenty-one years of age 
were arrested on the charge of prostitution, 3232 had been found dis- 
eased, 1777 had syphilis, 54.98 per cent. ; 1372 had other venereal affec- 
tions, 42.45 per cent., and 191 had scabies. , 

Of 7944 diseased girls of all ages arrested during the ten years, 
2681 were servant girls, of whom 1375 were minors, and 1306 were 
over twenty-one years of age. 

Of the 1375 servant girls under age, 652 were affected with 
syphilis, 639 with venereal affections, and 84 had scabies. Of the 



460 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

1306 servant girls over twenty-one years of age, 70 had syphilis, 550 
had venereal affections, and 55 had scabies. 

From these data, taken from Commenge's accurate work, we can 
infer that among the minor girls arrested by the police des moeurs 
in Paris, the proportion of the young girls found diseased is 37 per 
cent., while of those of age the proportion is 22 per cent. In reference 
to syphilis among 12,615 minors, there have been found 2651 or 21 
per cent, affected with syphilis, while of those of age of 14,392, 1777 
had shown manifestations of syphilis, or 12 per cent. This disease is 
about doubly as prevalent among minors as among those of age. 

Le Pileur, 30 physician of Saint Lazare from 1890 to 1899, found 
among 1963 diseased prostitutes 1011 affected with syphilis. Of the 
ion syphilitic girls he could follow the history of 718. Five hundred 
and nineteen had begun a life of shame at an age between thirteen and 
twenty years, while 199 had begun after reaching twenty-one years. 
Of the 718 women 69 had contracted syphilis before beginning the 
career of prostitution, some from their lovers and some from their 
husbands. Four hundred and eighty-nine had acquired syphilis in the 
year of their debut in prostitution, 101 in the second year, and 59 
somewhat later. As a consequence, 91 per cent, of these women had 
contracted syphilis almost at the very beginning of their career as 
prostitutes. 

Of the ion affected with syphilis during the service of Pileur, 
431 were registered in the Bureau des Moeurs as Mies soumises, and 40 
as girls in the brothels. Amongst the 431 girls free, 318 had acquired 
syphilis before their registration, and 113 after registration; 247 had 
contracted syphilis between the age of twelve and twenty years. 

Of the 40 women in the brothels, 33 had contracted syphilis before 
their registration, and 7 afterwards ; 28 contracted syphilis between the 
age of fifteen and twenty, and 12 between age of twenty-one and 
twenty-eight. 

The statistics of Dr. Barthelemy, 31 also physician of Saint Lazare, 
show that of 417 prostitutes affected with syphilis in his service, 219 
were minors. 

Jullien, also a physician of Saint Lazare, found among 1000 dis- 
eased girls, 823 clandestines and 177 Mies soumises. The age was 
from twelve to sixty-three years. Seventeen were between the age of 
twelve and fifteen, 24 at the age of sixteen, 527 between seventeen and 
twenty years, 289 between the age of twenty-one and twenty-six, 143 
from twenty-seven years on. 

From his statistics it results : that among 1000 diseased women, 

30 Le Pileur. Rapport a la Conference Intern, de Bruxelles. T. 1. 
32 Barthelemy. Compte rendu des seances de la Conference de Bruxelles. 
T. 1. 



SYPHILIS AND PUBLIC HEALTH 461 

56S were minors. Of 823 clandestine prostitutes, 340 were syphilitic, 
while of the 177 registered in the brothels, 81 were affected with 
syphilis. 

In reference to the age when syphilis was acquired, Jullien starts 
his calculation from the initial chancre. He found 123 chancres 
among his 1000 patients, of which 99 were among the clandestines, 
and 24 among the regularly registered prostitutes. He found 80 cases 
of hard chancre in minors, while 43 were in women above twenty-one 
years of age. 

Jullien derives the following conclusions : That the age when 
infection of syphilis mostly takes place is that of eighteen, somewhat 
less at the age of seventeen, and still less at the age of nineteen. 

It is of great interest to refer to a statistical table presented by Dr. 
Fournier, to the Congress of Brussels, which was taken from the city 
practice of Alfred Fournier, and from his hospital service of Hospital 
Saint Louis, Lourcine and du Midi. 

City practice — men io 3 ooo syphilitics 1432 minors 

City practice — women 1,000 syphilitics 313 minors 

Hospital practice — men 2,322 syphilitics 473 minors 

Hospital practice — women 2,949 syphilitics 1418 minors 

City practice was among people in good financial circumstances, 
while hospital practice was among the lower class of society, where 
there was lack of means. 

HIGH CLASS OF SOCIETY LOW CLASS OF SOCIETY 





MEN 


WOMEN 


MEN 


WOMEN 


First youth, 14 to 19 years 
Second youth, 20 to 29 years 
Maturity, 30 to 39 years 
Declining, 40 to 49 years 
Old age, 50 


8 
66 
18 

5 
3 


21 

58 
16 

5 
0.7 


13-5 

55- 
20. 

5- 

5- 


37-5 

52.3 

7- 

2.6 

0.6 






Fournier from all these data tried to show that hospital patients 
are infected with syphilis somewhat earlier than city patients ; in 
other words, syphilis is earlier acquired by the common people than 
by the bourgeoisie. Among women of the common class of people, 
syphilitic infection takes place at from sixteen to twenty-three years of 
age ; after this age the infection is more frequent among the upper 
classes of society. 

Finally the proportion of minors infected with syphilis in the upper 
classes of society is 14.32 per cent, males, and 31.3 per cent, females; 
in the lower class, 20.37 P er cent - males, and 48 per cent, females. 

We have already seen the large proportion of prostitutes which 
is given of girls not of age in Russia, and the enormous number of 
them infected with syphilis. Sperk 32 refers to syphilitic women ad- 
mitted for treatment in Kalikinski Hospital in St. Petersburg, between 
32 Sperk. " (Euvres completes." Vol. ii. 



462 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 



the years 1872 and 1875 ; 3104 women applied for treatment of venereal 
affections. These were all non-registered and requested admission of 
their own accord; of these 2165 were affected with syphilis, and 437 
of the syphilitic girls were between the age of fifteen and twenty. 

Seven hundred and six non-registered girls had been sent from the 
office as diseased., and 403 were found infected with syphilis. One 
hundred and fourteen of them were between the age of fifteen and 
twenty. 

Of 835 registered prostitutes, but free, treated for syphilis, 398 
were between the age of fifteen and twenty. Of 1261 girls, inmates 
of brothels, treated for syphilis, 696 were minors between fifteen and 
twenty years of age. 

Sperk's conclusion is that among non-registered prostitutes the 
average of syphilitic minors is 21.4 per cent., and for the registered 
prostitutes it is 50 per cent. 

The same conclusions were reached by Nicholsky, 33 who referred 
to the conditions of prostitution in Kieff. The girls practicing pros- 
titution are nearly all between sixteen and twenty-seven years of age. 
Among 495 prostitutes, of whom 192 were registered as free, 252 as 
residents in the brothels, and 51 as clandestines, he found that half 
of them were infected with syphilis at the age of nineteen, giving an 
average of 48.7 per cent. 

In 1842 Tait published the results of an inquiry into the causes 
and consequences of prostitution in' Edinburgh. He gave a statistical 
table, which he compiled from the clinical histories of the patients who 
had been treated for syphilis in the Lock Hospital in 1835. Of a round 
number of 1000 female patients, 42 were found to be less than fifteen 
years of age, and 662 were between fifteen and twenty, so that of the 
whole 1000, 704 were minors. 

Some interesting statistics were given by Le Pileur at the confer- 
ence of 1899. Among ion syphilitic girls under his service in Saint 
Lazare, from July, 1890, to June 30, 1899, he was able to obtain from 
582 the age of their first intercourse and when they began their life of 
shame. 



AGE OF DEFLORATION 




AGE OF DEFLORATION 




Years 10 to 11 . 6 


Years 


18 to 19 




67 


" II tO 12 


2 


" 


19 tO 20 




38 


" 12 tO 13 


8 


" 


20 tO 21 




24 


" 13 to 14 


. 24 


" 


21 tO 22 




II 


14 to 15 


• So 


" 


22 tO 23 




II 


15 to 16 


. 142 


a 


23 to 24 




3 


16 to 17 


. 106 


" 


24 to 25 




1 


17 to 18 . 86 


te 


25 to 26 




3 


Nicholsky, P. Remit 


' de morale 


progressive, May, 1889. 


Quoi 


:. by Minod 



" Statistiqnes de la syphilis et du chancre mou parmi les prostituees inscrites 
de Kieff." 



SYPHILIS AND PUBLIC HEALTH 



463 



TIME ELAPSED BETWEEN DEFLORA- 


TIME ELAPSED BETWEEN DEFLORA- 


TION AND PROSTITUTION 


TION AND PROSTITUTION 


Less than one year . . 270 


Six years ... 2 


One year . . . 103 


Seven years ... 12 


Two years ... 86 


Eight years ... 3 


Three years • ■ ■ 33 


Nine years ... 4 


Four years . . .21 


Ten years ... 7 


Five years ... 22 


Between 11 to 34 years . 15 



This table clearly shows that the most dangerous age for the girls 
is that between fifteen and sixteen years ; indeed, it points out the 
fact that 373 girls out of the 528, sixty-four per cent become prosti- 
tutes in less than one year after their defloration. Le Pileur from 
these statistics concludes that the most dangerous period for a girl 
is between fifteen and seventeen years of age. 

Statistics of the same kind have been given by Martineau, 34 who 
fully agrees with those of Le Pileur. He finds, however, that the 
most dangerous age is between seventeen and eighteen years. The 
arguments are nevertheless very weak for reaching conclusions of 
any importance. Anyway, we can say that more than half of all 
prostitutes are minors at the time when they start in their life of 
shame, and being inexperienced soon become infected, and conse- 
quently they are the cause of spreading infection. 

PREVENTION AND COERCION 



The States and sociologists have had under consideration this 
social problem, and preventive and coercive rules have been already- 
adopted. In France since 1862 there was added to the penal code 
Art. 331, which severely punishes any attempt to violate a girl under 
thirteen years of age. After thirteen years the girl is protected 
against an attempt with violence, but she is left to herself, if she is 
violated with her consent. This is just at the most dangerous period 
of life, when the girl on account of her natural weakness has to be 
most protected. Childhood ought to be protected against its own 
inclinations and against libertinage. The young girl is often a desired 
prey and is often abused on account of her feebleness and ignorance. 
When she has fallen she lets herself go down the slope. In Paris 
especially there is found the administration of moeurs and instead of 
being helped she is plunged to the bottom. The girl is arrested and is 
kept in jail for six months on the ground of prevention. Parent du 
Chatelet justified this way of doing, and Reuss said that in the con- 
ditions of society the registration of minor girls is an absolute and in- 
exorable necessity. 

34 Martineau. " La prostitution clandestine." 



464 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

In this regard Mme. J. Leroy 35 beautifully said that the maison 
de correction ought rather to be called maison de corruption, since it 
supplies the criminal court and the penitentiaries with the toughest 
characters. It has been already judged as injurious and must be con- 
demned. The youngsters who are sentenced to the house of correction 
have lost hope ; they have no more illusions, they know that it is hell 
for them, and that they are lost forever. 

The convent, especially in countries of the Catholic faith, has not 
given any too good results. The Good Shepherd, the penitents, etc., 
with their monastic and repressive rules, have given results similar to 
those of the prison. Parent-DuChatelet praised the Bon Pasteur in 
Paris, saying it is not at all doubtful but. that the establishment is a 
useful one, and if it did not exist it would be necessary to create it. 
This asylum was established by benevolent ladies and it was until lately 
supported by an annual vote from the City of Paris, and an allowance 
from the hospitals. The institution admits prostitutes who desire to 
reform ; feeds, clothes and instructs them, provides them with places 
when they wish to leave, or with work when they remain in the estab- 
lishment. It does not admit prostitutes under eighteen years of age, 
nor over twenty-five. It seems that beyond this age every effort has 
proved fruitless. They claim that no compulsion is used by the man- 
agers, and the girls are free to leave as they are free to come. As 
long as they remain they must obey the rules of the institution, which 
are stern and strict. 

From the report of the institution, according to Saenger, it results 
that in the first twelve years twenty prostitutes each year were admitted. 
The mortality was found to be very high, so much so as to reach 
20 per cent, of all girls admitted. In all twelve years 245 girls were 
admitted, of whom 40 were dismissed for insubordination, 2J left of 
their own accord and probably returned to their old calling and 15 
were returned to the police. The remainder were either restored to 
their families or placed in situations, in hospitals or elsewhere. This 
remainder, however, is 163, which in twelve years gives 13 and a 
fraction per year. Indeed, thirteen prostitutes per year have been 
reformed, but this number in comparison with the enormous army of 
prostitutes in the city of Paris is only an insignificant item. 

Mme. Leroy is right in her statement, that the rules of the convent 
form a deplorable system, which is just as bad as that of the prison. 
The places, the surroundings, the rules, the kind of work, all is against 
the possibility of giving good results in the reform and in the educa- 
tion of the fallen girls. 

35 Mme. J. Leroy. " Droits de l'Enfant." 



SYPHILIS AND PUBLIC HEALTH 



465 



JUVENILE COURTS 

Indeed, we feel very 7 well pleased with the system of the juvenile 
courts, as adopted in our American cities, and we are sure that these 
courts, when handled by capable men, will be of great advantage and 
will diminish the lamented evils. 

One of the best results of the establishment of juvenile courts has 
been that they have clearly established the causes which lead to 
juvenile delinquency and dependency. When society is no longer 
compelled to rely upon suppositions, but is armed with facts, it will not 
be difficult to restrain and diminish these evils and abuses. The 
juvenile court of Chicago has clearly established as a fact that juvenile 
delinquency and dependency, and also other social diseases, are due 
to parental ignorance, to parental neglect, to parental debauchery. In 
the first eleven months of existence of this court 1460 bad boys and 
328 wayward girls were tried by the court. At the same time the 
judges had been asked to decide the future of 786 homeless boys and 
641 neglected girls. The causes of dependency are shown by the records 
of said court as follows : 



CASES 

Lack of parental care . 

Drunkenness of father 

Drunkenness of mother 

Drunkenness of both 

Desertion by mother 

Desertion by father 

Desertion by both . 

Separation of parents 

Neglect by father 

Death of father 

Death of mother . 

Death of both parents 

Insanity of parents 

Poverty of parents 

Sickness of parents 

Incorrigibility 

Incorrigibility, preventable causes 

Incorrigibility, non-preventable causes 



GIRLS 


BOYS 


TOTAL 


l62 


I48 


310 


85 


75 


l60 


40 


52 


92 


31 


32 


63 


IS 


14 


29 


51 


96 


147 


10 


15 


25 


9 


7 


16 


8 


5 


13 


30 


53 


83 


41 


32 


73 


24 


4i 


65 


13 


19 


32 


3 


22 


25 


39 


4i 


80 


5 


3i 


36 


— 


— 


465 


— 


— 


395 



These data clearly show to what an extent parental neglect has 
to do with the future life of their offspring. 

The Juvenile Court was established in Cincinnati and Hamilton 
County on July 1, 1905. This court must not be used for criminal 
trials when avoidable. The institution of the juvenile court has re- 
moved the darkest blot from the pages of the history of the old 
criminal and police court. 



466 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

It was indeed the most heartrending spectacle to see children, 
tender in years, indiscriminately mingled in the court with notorious 
characters and hardened criminals of all kinds, forced to listen to 
coarse accusations and testimony, subjected to the same procedure, 
and condemned or released upon the determination of guilt or inno- 
cence of a specifically charged crime in the same manner as adults. 
It very rarely occurred that a child ever came away from such a place 
repenting of the wrong he had done. Yet from the juvenile court, 
where the child is treated kindly and is shown the wrong of his action, 
he comes out with exalted feelings of hope and encouragement, with 
mind and heart full of new ideals to be and do something better than 
he or she had ever done or been before. 

There is no doubt that environment plays a great role in shaping 
the desires and ideals of individuals. Environment, influences for 
good or for evil, are great factors in children before their will and 
power of discrimination are fully developed. For this reason, in order 
to preserve and develop the good faculties in children, it is necessary 
to remove from them whatever has a tendency to degrade. 

The special court room for young folks, separate from all others, 
secures privacy, which is so desirable for the hearing of their cases, 
since it does not crowd them into the regular court rooms. In this 
court every possible fact, material or personal, connected in any way 
with the present or past history of the boy or girl is fully considered. 
The personal history of the young person recited by himself is very 
significant and reveals his real life, and the conditions and elements 
which have shaped it. This preliminary work requires patience, tact, 
keenness of observation, and power of discrimination, and above all 
the ability to obtain the confidence of the young people. 

The investigation discloses the circumstances which are connected 
with the alleged delinquency or dependency of the boy or girl, the con- 
ditions of their homes, their school records, the quality of the neighbor- 
hood, the environment, the habits and character of their parents or 
relatives, their religion, creed, occupation, etc. 

The most of the minors who are taken before the court are 
accompanied by their mothers, who usually belong to the lower classes 
of society, representing that element upon which the evils of our social 
organization bears most heavily. The results of the sins of men and 
women are brought to light, and the saddest consequence is to see 
the young, who are in no way responsible, suffer. 

The judge who at present presides over this court is one of the 
most eminent jurists of Hamilton County, Honorable John A. Caldwell. 
He does not sit on a high bench, clothed in a long robe and look stern 



SYPHILIS AND PUBLIC HEALTH 467 

and severe, but on the contrary he is an everyday sort of a man, merry 
and cheerful., with a smile spreading over his countenance. With his 
kind, gracious and sympathetic manner, he takes a personal interest in 
every case, exercises rather the power of love than that of fear, and 
thus gains the confidence of the poor unfortunate children. 

The influence of the juvenile court has been felt in many homes 
where more than one lad and lassie has been guided away from en- 
vironments that threatened to precipitate them into the abyss of crime 
and social ostracism. 

The study of the special cases offers a field of great sociological 
interest and promises great benefit for our future generations. In one 
family the parents were separated. The father was a drunkard, of 
weak character. The mother was of questionable character. She had 
two girls, who were following the example of their mother; the judge 
committed the two girls to the house of a married sister, maintaining 
them under surveillance. 

In the case of a colored family the parents were separated. The 
father was a good, hard-working man, the mother, rather young and 
pretty, was frivolous and was living in a house of ill fame, together 
with her children. The children were taken away from her and com- 
mitted to an aunt. In another family the parents were also separated ; 
The father was blind ; the mother, a woman of low grade, was living 
with another man, and used a fifteen year old daughter for immoral 
purposes. The daughter was taken away from her and committed to 
the house of refuge. 

It would be a long task to bring before the reader all the sad and 
dolorous conditions of the families which are the preparatory ground 
for leading girls in the path of prostitution. In many cases the parents 
have been separated or divorced ; in many cases they have been living 
together, but they have been of a vicious and immoral disposition, and 
their children with both parents living have to call their father a 
drunkard and a deserter and their mother a prostitute. 

From the comparative study of the age of the children, it appears 
that from the age of ten to fifteen years is the most dangerous period 
for delinquency. In reference to immorality it can be said that many 
girls scarcely reaching the age of fifteen have been used and placed in 
the way of prostitution by their own debased and denaturalized parents. 

In reference to the crimes with which these small delinquents were 
charged, we will examine the report of the month of May, 1906. 

Delinquents! BoyS ? 6 

1 Girls 17 

93 



468 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

Incorrigibility .......... 22 

Destruction of property ........ 8 

Petit larceny .......... 6 

Jumping cars .......... 2 

Forgery .......... 1 

Immorality .......... 10 

Arson ............ 1 

Truancy ........... 34 

t^ , . ( Boys 26 

Dependents ■{ 

I Girls 21 

Improper homes 34 

Homeless .......... 13 

We must add that the juvenile court is a child-saving institution, 
which in co-operation with other institutions, and especially with the 
citizens, will successfully correct wrong tendencies of the delinquent 
youngsters, and remedy the evils which beset the life of the neglected 
and of the dependents. 

Before a juvenile is brought before the court a petition must be 
filed or a complaint has to be made to the prosecuting attorney of 
said court, and a time will be set for the hearing of the case. The 
juvenile must not be brought into court until the day set for the 
hearing of the case, and when a juvenile is taken into custody by an 
officer, he or she must be placed in the Children's Home, House of 
Detention or other suitable place, until a petition has been filed and 
a day set for the hearing of the case. 

The officer or other person, when a petition or complaint is filed, 
must be prepared to furnish the following information : 

1. Xame of the juvenile. 

2. The age of the juvenile, and if possible the day and month of 
birth. 

3. A brief synopsis of the facts in the case. 

4. The name and address of the person having custody of the 
juvenile. 

5. Name and address of the father or mother ; if he or she has 
no father, or in case he or she has no parents, or they are unknown, 
then the name and address of the guardian, or of some relative of 
the juvenile. 

The names and address of one or two witnesses to the facts, when 
it is deemed necessary. 

When a juvenile is committed to a public or other institution, the 
officer to whom the commitment is issued must obtain the receipt of 
the superintendent or other chief officer of the institution, to which 
he or she is delivered, and must also make return of the commitment 
to the court. 



SYPHILIS AND PUBLIC HEALTH 469 

The cases which are brought to the attention of the court are 
incredible, and much interest is aroused among the public. A 
charitable woman reported that a girl of sixteen had left her mother 
because of her evil, reputation, but was faced with drifting into a life 
on the streets. The girl after leaving home had obtained work, and 
boarded in a house. She lost her position, and had been told to leave 
her boarding house because of lack of funds to pay. Not being able 
to secure work, and being friendless, the street and its shameful life 
stared her in the face. The case was reported to the officers of the 
court. Occupation was found in an institution and then in a private 
house. 

Many cases of cadetism have been investigated. Three girls be- 
tween iourteen and sixteen had been enticed by a woman to her house, 
where she introduced them to men. 

Another object of this court is to place children who have no 
proper home in such surroundings as will most nearly approach a 
proper home. Indeed, the ideal place is the home itself. A home in 
the real sense of the word cannot be created by legislation, and the 
House of Refuge and other institutions are merely the best possible 
substitutes. The large number of children placed there make it lose 
the idea of a true home. The value of these institutions is in inverse 
ratio to the number of children placed there. In consequence when the 
erring girls can be placed in a good private house and there can be 
given them the idea of the home life, it is the greatest benefit that can 
be done to them. 

Miss Emma Woolley Utz, who is a Deputy Probation Officer of 
the Juvenile Court, asserted that children are seldom bad because they 
are born with evil in their hearts. In almost all cases which had come 
before the Juvenile Court the little ones have been forced into wrong 
directions on account of the conditions in which they were living, which 
seemed purposely arranged to conceal from them the right path. In 
nine cases out of ten the home environments, which should be the best 
and the purest, were the vilest and the most unwholesome of all. 

Bad food and bad clothing make the poor boys and poor girls 
weak in both body and mind. If they go to school, they cannot compete 
with the others, who are well fed and well cared for. The mothers have 
no idea of cooking, and if they attempt to prepare something it is unfit 
to eat. Many families live on the rotten vegetables which are thrown 
aw r ay in the dumps by the commission merchants. 

With such scanty and unwholesome food beer is given in plenty, 
even to infants, and is considered as nourishment. In some families 
beer is given in the place of coffee in the morning', and children go to 
school under the influence of beer and fall asleep at their work. 



470 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

In the first year, from July, 1904, to January, 1905, the Juvenile 
Court of Cincinnati took care of 582. In the second year 1241 children 
were legally before the court, of whom 888 were bovs and 353 were 
girls. Sixty cases were dismissed; new homes were found for 75 of 
the children; 9 were boarded in good houses, the father or mother 
paying for their maintenance ; 430 were sent to institutions, the ma- 
jority because of dependency; 582 were released on probation, or on 
their good behavior, the probation officers being either detailed to 
look after them, or they being instructed to report weekly to the 
court. 

Of the 582 released on probation, Judge Caldwell stated that not 
two per cent, have had to be returned to the court on account of other 
misdeeds. There were 73 cases of children neglected by their parents, 
who were allowed to return to their homes, their parents being placed 
on probation and compelled to care for them properly. Besides this 
large number of children cared for officially, some 300 other children 
were looked after, who were never legally before the court. A certain 
number of young girls charged with immorality were examined by 
the physician and nearly all were found affected with some venereal 
ailment. They were sent to the Hospital and when cured were com- 
mitted to the House of Refuge or to some other institution. 

Children are no longer locked into jails or police stations with 
criminals. They are temporarily guarded in the house of detention, 
where they are looked after by women. In a short time this court 
will have a place of detention of its own, where children will be guarded 
by the officers of this court. 

Indeed, it is between the age of ten and seventeen when the best 
and most lasting impressions are implanted in children. Therefore it 
is of great importance not only for the future of the child, but also 
for the good of the state, that methods be adopted to preserve and 
develop whatever is best in these children. This court has full juris- 
diction over all dependent, delinquent and neglected children under the 
age of seventeen. It takes this jurisdiction away from the justice of 
peace, mayors of villages and police courts. It has not only the right 
to care for and punish children but to enforce the parental responsi- 
bility as well, and punishes all those encouraging and causing de- 
linquency in children by fine and imprisonment. 

The children who come under the care of the juvenile court are 
so treated that no possible stigma may remain on them in later years. 
While complete records of each case are kept, yet the trials are held in 
strict privacy, and by law the records of this court cannot be used in 
anv other court against the child. It is not a criminal court, but a 
court of equity. It is the aim of this court that the noble heart and 



SYPHILIS AND PUBLIC HEALTH 471 

the humane tendencies, which are found in every boy and girl, shall 
be encouraged, that with them a good character may be built up. In 
the cases of delinquency, the aim is reformation and regeneration, 
which in many cases is obtained. 

The efforts of this humane institution have in many cases rescued 
childhood from squalor and the shadow of sin, from poverty and 
physical diseases, from misfortune and the grinding of misery, and 
taken those poor unfortunates who would have succumbed as victims 
of vice and crime to the healing atmosphere of wholesome environ- 
ments and kindly sympathy, and have thus changed entirely the path of 
their lives. In the by-ways are found the poor unfortunate youths 
wandering away into crime, and from there they are led to the high- 
ways of uprightness. Those poor boys and girls so rescued have a 
chance to grow into a manhood and womanhood that is not a menace 
to the community and a shame to themselves. It saves the helpless 
children from suffering, brings the vicious to virtue, and so restores to 
moral, mental and physical health those poor unfortunates upon whom 
especially venereal diseases and syphilis are preying. 

We have dwelt somewhat long on the mission of the juvenile 
court, not because it is a home institution, but because we expect from 
it a great advantage for the future generations. We would like to 
extend the jurisdiction of the court to all persons under eighteen years, 
and then we should see very little of the prostitution of minors. We 
hope that this system of juvenile courts will be adopted in every 
country, and the benefit will soon be found out. 

In France, for instance, there is the paternal correction. The 
father takes his incorrigible son before the judge so as to obtain a 
punishment for him. It is one month of detention in the house of 
correction for boys or girls less than fifteen years, and six months for 
youngsters between fifteen and twenty-one years. The judge commits 
the boy or the girl to the house of correction, and according to the 
condition of the family the parents have to pay the expenses, or in 
case of poverty they are sent free of charge. 

It is easily understood that very few will send their children to 
be committed with others by the court, leave them in a society of boys 
or girls much more corrupted, for the result would be the complete 
ruin of the young, together with the stigma of the commitment by 
the court. 

Professional schools, convents, etc., have had so far no better 
results. Mme. Leroy calls attention to the fact that the so-called 
fillcs repenties in France cannot find any occupation except amongst 
religious orders. Although the church has not been more successful 
than the government, yet we can say that it has been prompted by 



472 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

a charitable motive. It has at least tried to do something- for lost 
girls, at the time when society offered to these unfortunate victims 
of the brutality of man nothing but a scornful repulsion. 

In Germany the age of protection is up to fourteen years, whereby 
a special punishment is inflicted on those who procure an attempt on 
their children or on minors placed under their guardianship. Art. 
181, 182. Seduction of a virtuous girl is punished with imprisonment 
up to sixteen years. 

The Prussian law of 1878 tried correctional education for aban- 
boned children from six to twelve years, who were delinquent and 
could not be prosecuted on account of their extreme youth. Such a law 
had only a repressive purpose, and no moral or educational pur- 
pose. It was replaced July 2, 1900, with the object, not of punishment, 
but of reform. This law now concerns minors under twenty-one 
years and takes care of all children morally abandoned, and principally 
of those who refuse to heed the authority of their parents, or of those 
who remain in the society of dangerous and licentious people. 

On May 27 the Minister of the Interior sent a circular to the 
presidents of the judicial districts concerning the prostitutes of minor 
age. When a girl under eighteen years abandons herself to professional 
vice, either subject to the control of the police des moeurs, or in con- 
dition to be placed under surveillance, the authorities are required in 
the sense of this law on the tutelar education of minors, to apply this 
law. The rules of the police des moeurs are to be applied only to 
those to whom the court has refused the tutelar education, and when 
the appeal to the last decision has been refused. 

In Germany the number of these poor fallen girls is quite con- 
siderable and is under the direction of the pastors of the different 
congregations. 

In England the limit of protection for a girl is sixteen years, and 
much heavier punishment is given the betrayer if the victim of the 
attempt is under thirteen. Whoever makes an attempt on a girl under 
sixteen years is punished, and the proof that the girl was already cor- 
rupted does not diminish his guilt. The law not only punishes those 
who commit violence or attempt to do so on minors less than sixteen, 
but also those who allow, or abet, the perpetration of the outrage in 
their houses, or in places of their purtenance. If a young girl between 
thirteen and sixteen years is taken into a house of prostitution, or into 
any other place for immoral purposes, although with her own consent,, 
the proprietor, the owner, or the guardian is punishable with imprison- 
ment with hard labor. If the girl is over sixteen and less than eighteen", 
she is not protected, unless she has been taken from her parents or 
guardian without their consent. If taken against their consent, the 



SYPHILIS AND PUBLIC HEALTH 473 

procuress, or the proxenet who has caused the ruin of the girl less 
than twenty-one, is severely punished. 

In regard to the action to be taken against young prostitutes, the 
English rules have a peculiar character. The intervention of the gov- 
ernment is combined with that of private interests, or better, the govern- 
ment helps private initiative. A large number of powerful philanthropic 
associations are organized for the needs. These associations in France 
are in the hands of the government ; in England they are active through 
the union and the free action of their citizens with an executive power. 

Minod says that the result is that in France with the repressive 
rules of the police the criminality of minors increases, while in Eng- 
land it decreases. This is a great argument for maintaining the super- 
iority of the English organization for the repression and prevention of 
vice among children. 

INDUSTRIAL SCHOOLS 

Since 1866 an act of the English Parliament authorized any person 
to bring before a judge or before a magistrate, any boy or girl under 
fourteen years who had been found begging or a vagabond in the 
streets, or if found in company with suspicious characters. An amend- 
ment to this act was adopted in 1880, extending the same disposition 
to children found lodging, living or residing with common notorious 
prostitutes, or in a house harboring lewd women, or kept for immoral 
purposes, and also children found in the company of prostitutes. 

In 1889 a new amendment made this same act applicable to chil- 
dren living w T ith one prostitute, or in a house frequented by a prostitute 
for immoral purposes. 

Under this law, by private charity and initiative, a great amount 
of work of preservation and of rescue has been accomplished. Indus- 
trial schools, reformatories, houses of refuge have been instituted by 
private initiative. The government has only given its authority and 
support to the institutions. The government leaves to the directors 
of the institutions full liberty in their administration, allowing them to 
choose their own officers and employees. They have legal power to 
keep children committed to their care, and the government allows sub- 
ventions with right of control. 

In England the institution of these establishments for prevention 
and reform was not until 1854, and now there is no city in England 
which has not its industrial school, its school of reform, or its house 
of refuge. 

The industrial schools take children who are not delinquent, but 
only dependent, and who, left to themselves, on account of improper 
homes would be started on a dangerous route. The school of reform 



474 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

has some similarity to the French maison de correction; here are com- 
mitted delinquent children, and under good rules they try to reform. 
The houses of refuge are nearly the same as industrial schools, but 
they have no subsidy from the government, and are kept by private 
charity alone. 

The work of rescue, reform and prevention has a center in a 
general society, which has the control of all like institutions, and helps 
those deficient in means, and tries to obtain the foundation of others. 
It is the union of the reformatory schools and houses of refuge, which 
has its seat in London. Every two or three years they hold a general 
meeting for the purpose of studying improvements to be introduced 
in the struggle against vice. They have a monthly bulletin with the 
title of " Seeking and Saving." The union comprehends 666 institu- 
tions of prevention or reform under their supervision. 

For that which concerns the reform and rehabilitation of the 
young prostitutes in England, there are a large number of institutions 
on the same principles as the others, under the name of the Rescue 
Society, which has under its surveillance many hundreds of young 
girls kept in different institutions. 

It has been found that large institutions, with their routine of 
administration, with a large number of girls, have rather a tendency to 
estrange them, and remove from them the affection for the family life. 
For this reason in England they are trying to establish small institu- 
tions, to take girls in small numbers, so that their school shall more 
closely resemble family life. 

In the United States we are trying now to place the houses of 
refuge, the reform farms, etc., on the cottage system, so that only a 
limited number of boys or girls are, like in one family, under the 
direction of a teacher or of a matron. 

Prevention is the object, and the most useful institutions are those 
which help unhappy and unfortunate girls in danger of being lost, 
which give them instruction and education, and so furnish them the 
means to procure work, and with their honest work to earn their living. 

Indeed, in order to diminish the evil of prostitution, we must 
begin by stopping the minors, and bring them to the right path of life 
by just and friendly means. In France, in 1892, the committee for the 
defense of children brought to justice established that: It is neces- 
sary to consider as vagabonds minors of sixteen years who have left, 
without consent or without excusable cause, the house of their parents 
and guardians, or the educational institutions where they had been 
placed by the authorities to whom they had been trusted when found 
wandering about, or in lodging houses without any regular occupation, 
or getting their resources from debauchery or forbidden professions. 



SYPHILIS AND PUBLIC HEALTH 475 

In the following year the Court of Paris decided that a minor 
girl less than sixteen should not obtain her means of living from public 
prostitution, and her corruption should not exempt her from the obliga- 
tion to have a home and to do some work. Having placed prostitution 
together with vagabondage, it succeeded in having girls less than six- 
teen arrested and committed to the house of correction or to any rescue 
home. 

It is interesting to refer to a study of Marc Reville, a lawyer of 
the Court of Appeals of Paris, on the prostitution of minors according 
to the penal law. 

He said : Prostitution is a free act, which cannot be restrained 
but by the respect for liberty or for the existence of others. A woman 
has the right to dispose of her body just as she likes, but she must 
have full knowledge of what she is doing, and of the consequences. 
For this reason prostitution in a strict sense has no dependence on the 
penal law, but it can and must be prevented and suppressed among the 
minors, who must be protected on account of their inexperience in 
the matter of morality and of civil capacity. 

Law and private initiative have to go together, and the important 
question is to oppose poverty and proxenetism. Societies of patronage 
for poor girls are of great assistance. The government can only 
repress, and it remains for private initiative to bring to justice pro- 
curesses and all who are recruiting young victims. The girls who are 
willing to return to their families have to go back to them, if the latter 
can assure honorability and sufficient financial means to protect the 
young fallen. Best of all is the commitment of the girl by the juvenile 
court to the different institutions, where they can be educated and 
instructed. The society of patronage has to look after the girl dur- 
ing her education, and when she has given evidence of reform, it then 
finds the way for her to return to honorable life. It is better for 
girls, when they behave themselves, to be placed in some other institu- 
tion of less austere rules, and finally to give them to families, so as to 
have them used to family life. The girls have to look to the society as 
their friend and to consider it their resort in case of necessity. 

When the society for the abolition of the surveillance of prostitu- 
tion was agitating the question of suppressing the police des moeurs 
before the Municipal Council of Paris, Mme. Emilie de Morsier re- 
marked that the question of minors ought to be considered first by 
the Council. Indeed, female minors are more directly and more un- 
justly persecuted by the police, and for such the responsibility of 
society and of the state is much more serious. According to Lecour 
more than 120 minor girls have been registered as prostitutes even- 
year in Paris. Those poor girls, placed in unfortunate conditions, sur- 



476 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

rounded by bad examples, are too weak to resist privations. They 
give way to the temptations, and once they have fallen into the fatal 
pit, they find the police, representatives of the government, push- 
ing them on downward. The fatal struggle begins between the police 
and the poor woman, who mad with the terror of losing her liberty, 
seeks to conceal herself; the end is the physical and moral death of 
the victim. 

From all these considerations it was decided that prostitution of 
minors of both sexes up to eighteen years, even though not habitual, 
should be assimilated with vagabondage. That prostitutes of minor 
age have to be allowed special proceedings before the committee, which 
orders that the court, in the interest of the child, returns the child to 
his or her parents, if they can give proof of morality. Otherwise the 
girl or boy shall be committed to an industrial school, or to a cor- 
rectional house until the age of twenty-one. The parents when found 
unworthy and negligent towards their children are made responsible 
in all or in part for the expenses of guardianship and the education of 
their children committed to state institutions. 

In our judgment the juvenile court which has been instituted in 
many American cities covers the ground much better, and insures 
better results in the reform and education of delinquent and of depend- 
ent children. 

A minor is a person who before the law is considered to have not 
yet enough power of reasoning and of discernment. This power of 
judgment is necessary to govern ourselves in order to make legal all 
acts concerning civil life. Consequently, if a minor is forbidden to 
sign documents, he is not even to be allowed to dispose of his own 
person. Minors must be protected by the state, and in the same way 
as they are not allowed to administer their properties, which they could 
lose on account of inexperience, they must be protected in regard to 
their person against seduction. The punishment applied in different 
degrees is considered by Mile, de Miilinen as a good preventive for 
crimes against morality among minors. The division of the ages 
would furnish the degree of the crime, considering childhood until 
twelve years, adolescence from twelve to sixteen, and then from sixteen 
to majority. A violence committed on children ought to be made a 
capital crime; on adolescents a crime; on girls near majority, it would 
come under the cases of violence. 

Dr. Fiaux would consider the infection of a minor with syphilis a 
crime. At the same time punishment must be insisted upon for any- 
one who has not only attempted to corrupt a minor girl, but also for 
anyone who will excite, abet and favor the corruption of the young 
of both sexes. 



SYPHILIS AND PUBLIC HEALTH 477 

This, however, leaves entirely untouched those who keep brothels 
and houses of prostitution where are harbored adult prostitutes. Here 
we find ourselves in the presence of the much discussed and difficult 
question, surveillance of prostitution, or abolition of all rules. It is 
true that so long as the markets are open, the merchandise will be 
always in demand. The governments fix rules, license prostitution, and 
consequently prostitution and proxenetism must flourish. The aboli- 
tionists consider the regulation of prostitution as establishing a social 
profession of the procuresses. The young prostitutes find in the pro- 
curess their support and their protection, not only from the dangers 
connected with this profession, but especially against the police. 

Any system authorizing, recognizing or licensing prostitution is 
repudiated by the abolitionists, and they want it suppressed. Indeed, 
they do not care to suppress the system of surveillance on account of 
its purpose, but for the more important question, whether, in reference 
to the public hygiene, free prostitution, or licensed prostitution is 
better. The abolitionists consider the rules of surveillance of prosti- 
tution entirely insufficient for the purpose. Furthermore, they attack 
the principle of licensing as false and immoral, because it is based on 
the wrong idea that prostitution is a necessary evil. That prostitution 
is an evil is admitted by everybody, even by those who enjoy it. 
From the fact of the existence of prostitution there cannot be made a 
good reason to legalize its exercise, and recognize it as of public utility. 

They rightly maintain that licensing prostitution is a cause of 
demoralization. It is a disgrace for a man to obtain women who sell 
themselves or are placed at his disposal by the public authorities, and 
with whom the commerce is entirely free from any responsibility for 
the man. Where there is no responsibility, there is no morality, and 
morality and liberty are the essential conditions of responsibility. The 
system of licensing prostitution takes liberty from the woman, and all 
the responsibility from the man. 

When the woman gives herself for money, she commits a horrible 
crime, for which she is placed beyond the protection of the law ; the 
man who pays the woman to satisfy his carnal appetite, attends only 
to a natural act, which is granted to him by the law, and moreover, the 
state guarantees also the quality of the goods. Indeed, it seems that 
morals are only for one sex. The morality of woman is one thing, and 
quite another is the morality for the man, and these principles are 
upheld by the rules of the government. 

There is no doubt that the state cannot diminish the carnal 
appetite, the sexual passions, which the abolitionists believe to be in- 
creased by the licensing of prostitution. We, too, agree with them, 
that the best way to combat the evil of prostitution is the moral prin- 



478 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

ciples, the dignity of the man, and the respect of the woman. But 
these moral rules are based on instruction and on education, and will 
only be practiced by the smaller part of society, which consists of those 
who can obtain a liberal education. 

Rules of the police, which have for their result the plunging of 
the woman into the abject state of prostitution and keeping her there, 
should be abolished. In many cases, if the woman had been left free 
she would have found her way to reform, and rescue herself, which 
has been precluded by the arrogance of the police agents. While the 
police persecutes the girls, yet they protect and support the houses of 
prostitution, and this conditions of affairs is the reason why the girls 
look to the procuresses for their patronage and protection. 

Very often the police agents take arbitrary powers, violate all 
principles of legislation, and entirely disregard personal liberty. Al- 
though we look upon a good regulation of prostitution with in- 
terest, and consider it of public good, yet we severely condemn the 
extreme measures which touch upon persecution. 

According to the German Strafrechts reform, as referred to by 
Neisser, prostitution can be punished. It is considered a professional 
debauchery. The way of living of the prostitute is against morality 
and is condemned by the public opinion as a dishonor. It has a bad 
influence on young people, among whom it destroys the inclination for 
family life and leads them to roughness and prodigality. The woman 
who practices prostitution, although she had in the beginning some 
moral sense, has lost every feeling, and undergoes a physical and moral 
degeneration. She is unwilling to give herself up to any work, loses 
every moral sense, loses her memory, what she says has no sense, and 
she often lies, just for the pleasure of lying. 

Step by step she constantly descends, from the house of prostitution 
to the jail, from the jail to the hospital, and back again, until she is a 
wreck and a charge upon public charities. 

If we do not consider prostitution as a crime in itself, yet we must 
see in it the beginning of a criminal life. They are rejected by society 
and find easy association with criminals, whom they help and abet in 
their nefarious enterprises. For these reasons, if prostitution cannot 
be punished as a crime, it has nevertheless to be combated as profes- 
sional prostitution, in the view to morality and in the interest of society. 
If also prostitution could be punished, the result would be of no bene- 
fit. As Liszt 36 said, it is necessary to study the origin of the crime, 
which is rooted in the social conditions. The punishment strikes the 
individual alone, but does not change the social conditions, and as a 
consequence it is only of secondary importance in its influence on 
the criminality, causing neither increase nor diminution. 
36 Liszt. " Bekampfung des Verbrechens." 



SYPHILIS AND PUBLIC HEALTH 479 

From all these considerations we can say, that with the best will, 
the state, legislation, society, by means of punishment, of ostracism, 
will- not be able to chang'e the conditions of this social evil. With edu- 
cation and with moral inculcations only a small number of the best 
class of people will be reached, and yet the venereal diseases, and 
especially syphilis, will continue to spread without any restraint. The 
teaching of the venereal peril as advocated by Valentine will be of 
some benefit for a few thoughtful ones who consider the sad conse- 
quences for their future life from the illicit gratification of the sensual 
appetite. 

Even* means which can check the spreading of the venereal dis- 
eases, and especially syphilis, must be employed with all energy possible 
in order to succeed in stamping out so dangerous a scourge of society. 

If we turn now to consider as physicians the venereal diseases, 
we will see that gonorrhea, chancroids and syphilis are eminently 
contagious. As contagious diseases they must be treated and those 
infected must be compelled to subject themselves to a good scientific 
treatment, and in the same way the infected have to be isolated so 
long as there is danger of spreading infection. 

For this reason, setting aside the question of morality, we will 
see that a well-regulated system of surveillance of prostitution will 
have and has a very good effect, not only as a preventive means against 
the spreading of infection, but also as beneficial for the unfortunate 
girls, who, when infected, are compelled to undergo a good treatment 
and save themselves from the ravages of neglected syphilis. 



IV 

THE REGULATION OF PROSTITUTION IN THE PUBLIC 
PROPHYLAXIS OF SYPHILIS 

The statement, so often repeated, that the regulation of prostitu- 
tion is an implicit forbearance of the authorities, even a legalization of 
the crime, although true in an abstract way, does not, nevertheless, 
bear any weight when the health of the public is at stake. The idea 
alone that prostitution is to woman what crime is to man, calls for the 
necessity of a police surveillance. The same physical and moral char- 
acteristics are found in the prostitutes as in the delinquents, and every- 
body knows the relations and the sympathy which exist between these 
two classes. Yet like crime, prostitution has existed from the remotest 
times of society, and has always been subject to some form of 
regulation. 

Prostitution, to use the words of Sanger, 1 is coeval with society. 
In every age there have been men who, opposed to the marriage ties, 
and craving for lust, have created a demand for illegitimate pleasures. 
The weakness of the woman excited by passion, together with the idea 
of gain, has made it possible. 

In fact prostitution is found to shade with its dark colors the re- 
motest mythological figures. It can be traced, as Sanger said, from 
the earliest twilight in which history dawns to the clear daylight of our 
days, without pause or a moment of obscurity. 

In Biblical history, prostitution appears as an existing fact. The 
legend of Tamar, who covered her face and, wrapped in a veil, sat in 
an open place . . . and Judah took her for a harlot because she had 
covered her face, shows that prostitutes covering their faces were rather 
common in those times. From the books of Moses it is clearly shown 
that prostitution was common among the Jews, whose morals had 
been badly influenced by their sojourn in Egypt. 

Moses with his great wisdom and sagacity established strict and 
inflexible laws to check prostitution, and punished adultery and rape 
with death. He formally commanded, " Do not prostitute thy daughter, 
lest the land fall to whoredom. . . . There shall be no whore of the 
daughters of Israel." 

He tried to check the progress of venereal diseases among both 
1 Sanger. " The History of Prostitution." New York, 1899- 

480 



THE REGULATION OF PROSTITUTION 481 

sexes, and in Leviticus forbade sexual intercourse and all associations 
with persons afflicted with flow from the genitals, which was without 
doubt what we call gonorrhea. Although Moses had given such 
earnest laws in order to eradicate evil customs from his people, yet 
male Jews went to have intercourse with foreign prostitutes — Syrians, 
Moabites, Midianites, who were neighbors of the Jews. Some of those 
women, debauched and led by vicious tendencies, had invaded the land 
of Israel. To them, however, was forbidden, until the time of Solomon, 
admission into Jerusalem and into the large cities. Those prostitutes, 
driven to the highways, lived in tents, pretending to exercise the trade 
of peddlers, while they followed the calling of harlots. 

Moses pursued a policy of tolerance so long as the practice of 
those prostitutes did not offend the laws of nature. When he found 
that they were inviting young Jews to participate in the revolting 
worship of Baal, then the ire of the legislator rose and he set up 
severe punishment, not only on moral and religious, but also on hygienic 
grounds. His wise laws were followed and inculcated by Aaron and 
his successors. An express command forbade the establishment of 
groves near the Jewish temples, in order to avoid shady retreats, which 
might afford possible convenience to prostitutes. 

Solomon, who with his wisdom associated a great tendency for 
sensuality, repealed the just restrictions of his predecessors in regard 
to prostitutes, and allowed them to practice their calling even within 
the city of Jerusalem. History says that the prostitutes then multiplied 
so fast that they were wandering on the hills committing obscene acts 
under the trees, and they were even seen in the temple and in its courts. 
That sacred edifice at the time of the Maccabees had been changed into 
a brothel where meretrices were swarming. 

Prostitution was exercised in Judea in spite of the severe ordi- 
nances, and from an early period never lost its foothold, so much so that 
the prostitutes were recognized as a class, although stamped with the 
ban of shame. In these conditions, the best that could be done was to 
set forth restrictive measures in order to protect the health of the 
masses. 

The old Egyptians, according to Herodotus, had lax and ludicrous 
customs. Their deities, Isis and Osiris, as types of the sexes, made 
their religion very suggestive. In Chaldea their religion enforced pros- 
titution, and every Babylonian female was compelled to sacrifice herself 
in the temple of Venus Mylitta. Among the early Phenicians, obscene 
festivities were dedicated to the deity Astarte, and among Persians to 
Mithra, with the same voluptuous and obscene rites. 

The first attempt to regulate prostitution was made amongst the 
old Greeks, when Solon formally established houses of prostitution 



482 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

in Athens, which were filled with female slaves. They were bought 
with public money and were kept there to satisfy male visitors. The 
money gained in these houses was the property of the state, and a 
temple was built to Venus, the courtesan, with the funds proceeding 
from the infamous trade. 

The persons who kept houses of ill repute, so-called Dicteriades, 
were kept apart from the Athenian women of repute, and when in the 
street had to wear a special dress as a stamp of infamy. They had lost 
all rights of citizenship, and if a procurer or a procuress had been the 
cause of introducing into the Dicterion a free-born Athenian girl, death 
was the penalty. The law branded prostitutes and their accomplices 
with infamy, and their children were bastards and were forbidden to 
inherit. They could not associate with other youths, and could not 
acquire the rights of citizenship unless they had performed an act of 
bravery. 

Laws governing prostitution are found among Romans dating 
from the time of Emperor Augustus. The prostitutes were required 
to register themselves in the office of the sedile. They had to go per- 
sonally to the aedile, give their age, place of birth, their real name and 
the name they intended to assume in their shameless career. The 
sedile tried his best to recall the misled woman to the path of righteous- 
ness, but failing in it he issued her the license, licentia stupri, ascer- 
tained the sum she was to ask of her customers, and entered her name 
on the list. The prostitute once inscribed had incurred the stamp of 
infamy, and no repentance, no marriage, nothing could wipe it away. 

In those times, too, there were clandestine prostitutes, who were 
not registered and who were called prostibulce. The aedile was com- 
pelled by law to arrest, punish and drive out of the city all unlisted 
prostitutes, but it was never done. Although the habits of the old 
Romans were rather luxurious, yet a married man who visited a house 
of ill fame was an adulterer and liable to the penalties of adultery. A 
frequenter of such places was called a moechus or a scortator as a 
rebuke. 

It was well known at that time that secret diseases were arising 
from sexual intercourse with prostitutes, and Juvenal and Martial allude 
to some disgusting diseases, which resembled syphilis. Celsus described 
diseases of the generative organ as the result of venereal intercourse. 

The idea of a woman affected with secret diseases made her 
despicable, and she was called aucunnuenta, and had to pray Juno 
Fluonia for relief. As a remedy an herb was given called in Greek 
Bonbomion, which was converted by the Romans into the name of 
Bubonion, and was then applied to a disease, which modern science still 
calls bubo. It was said of a diseased woman " haec te imbubinat." 2 
2 Scaliger. Quoted by Sanger, p. 85, 1. c. 



THE REGULATION OF PROSTITUTION 483 

Diseases of a secret nature contracted by illicit intercourse were 
called morbi indeccntcs, and Roman physicians declined to treat this 
kinds of ailments. Anyone who was afflicted with these diseases was 
restrained by shame from confessing his secret, and when discovered, 
was driven to seclusion. Under Nero a public physician was appointed 
as archiater, which position was filled by Andromachus for the em- 
peror's person, and others were appointed to attend the people called 
archiatri populares, who in consideration of their privileges were bound 
to treat the poor free of charge. Many of the diseases which they had 
to treat could be traced to prostitution. 

The first idea of legislative rules tending to regulate prostitution 
are found in France in the Capitulaires of Charlemagne. He was bitter 
against common prostitutes, whom he directed to be scourged, but on 
the other hand he excused women who granted pleasure to rich people. 
He also inflicted severe penalties on all who kept houses of debauchery, 
or harbored lewd women for the purpose of prostitution. 

Louis VIII. tried to regulate prostitution, but he was not success- 
ful. The task was resumed by Louis IX., who strove to check the evil 
of prostitution in France. He directed that all prostitutes and all per- 
sons making profits out of prostitution were to be exiled. If they were 
found again in France after their expulsion, they were severely 
punished. On account of fear, decency was enforced, but the morals 
at large had to suffer so much that these arbitrary laws were repealed, 
and prostitution allowed under certain restrictive measures. 

From Louis IX. to Henry II., from Henry II. to Louis XIV., there 
is a continuous alternation of severe penalties against prostitution, and 
repeals of the same. Louis XIV. was the first to provide prisons for 
the detention of prostitutes and he drew a broad line between licentious 
women and true prostitutes. The first, who were not prostitutes, had 
a right to all the privileges of accused persons, sentences rendered were 
subject to appeal, and their punishment was usually a fine. For the 
prostitutes the proceedings were summary, they were sentenced, im- 
prisoned or exiled without right of appeal. Yet on the authority of 
Parent-DuChatelet, in spite of so many laws, brothels were licensed by 
the police, and prostitutes were never troubled unless on complaint of a 
responsible person. 

In 1 79 1, after the legislation of the monarchy had been abolished, 
the republican legislation made no reference to prostitution, leaving it 
open and free. As a consequence, prostitutes monopolized streets and 
public places, and Paris was scarcely habitable as a residence for modest 
women. This caused complaints to the Executive Directory, and in 
1796 it was earnestly urged upon the Council of Five Hundred 
to establish restrictive laws for prostitution. Several attempts were 



484 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

made by the prefects of police to make effective a severe regulation of 
prostitution. Indeed, the government had gradually assumed control 
of the prostitutes, and although without constitutional warrant, exer- 
cised full authority, so that the deficiency of the law could be scarcely 
perceived. 

Towards the end of the fifteenth century, on account of the fear- 
ful spreading of syphilis amongst the populations, public attention was 
directed to the subject of sexual diseases. These diseases usually mak- 
ing their first appearance on the genitals were called for some time 
pudendagra. In London there were established public regulations in 
order to prevent admission of persons affected with these diseases into 
the houses of prostitution. The police maintained a constant watch 
on anyone who showed symptoms of this infirmitas nefanda. 

In 1497 in France, by an ordinance of the Parliament, all persons 
affected with large pox were ordered to vacate the city within twenty- 
four hours, and not return until they were cured. Hospitals were 
prepared for those who were so sick that they could not move, and 
enough money for the journey was supplied to those so exiled. As 
early as 1497 a house was opened in Paris for the purpose of treating 
patients infected with syphilis, but the treatment was still left in the 
hands of quacks and of barbers. 

Although the treatment at that time consisted mostly of decoc- 
tions of sudorific woods, barks, etc., yet we find that in the beginning 
of the fifteenth century in Rome, Jacopus Berengarius da Carpi was 
using mercury in the treatment of syphilis. It is asserted by Fallopius 
that he used inunctions with mercurial ointment, and by these means 
he obtained successful cures. His services were liberally paid and he 
accumulated a large fortune, which at his death in Ferrara in 1530, was 
left as an inheritance to the duke of that city. 

The barbarism of the Middle Ages dominated even in the treatment 
of the poor unfortunates affected with syphilis. Not until 1614 was 
the project of the parliament of France realized and a hospital for the 
pauvres veroles opened. Patients when admitted and when discharged 
were soundly whipped as a punishment for having contracted the dis- 
ease, a practice which kept many persons from applying to the hospital 
from fear of showing their condition, and thus it was gradually 
abandoned. 

Under Louis XIV. a hospital prison for the prostitutes was 
founded, la Salpetriere, but admission was forbidden to those suffering 
from syphilis. The urgency of the cases applying for treatment 
showed the necessity of admitting syphilitic prostitutes also, and a 
small room was arranged to accommodate them. This, however, was 
not sufficient, and was dangerous on account of the overcrowded con- 



THE REGULATION OF PROSTITUTION 485 

dition. and finally the government allowed the use of a ward in the 
hospital of Bicetre for treatment of syphilitic prostitutes. 

For many years afterwards severe cases of venereal diseases were 
sent to Bicetre, and milder ones were kept at la Salpetriere. The way 
in which the patients were treated, according to the report of Cullerier, 
surgeon in chief, and referred to by Parent-DuChatelet, was absolutely 
abominable and a disgrace to humanity. In reference to treatment 
only, they had but few remedies, and patients were treated in turn. 
While some were treated, the others were obliged to wait months be- 
fore they could get their treatment. As a consequence, many died 
before they reached the time for their turn. It is not necessary to 
say that with this horrible state of affairs, the mortality was frightful. 

Owing to the reports of Cullerier, the government finally took 
action, and in 1789, removed the prisoners from Bicetre and made 
room for the accommodation of syphilitic patients. The means at their 
disposal were just the same, no conveniences for treatment, no baths, 
and it made necessary urgent reforms. The republican government 
then placed at the disposition of syphilitic patients the hospital of 
Capuchins, which was enlarged, arranged with the needed conveni- 
ences, provided with gardens, and was called L'Hopital du Midi. 

It w T as found barbarous and unjust to admit female patients of 
good moral character, who were affected with syphilis without their 
fault, together with vile and debauched prostitutes, suffering the 
ravages of syphilis on account of their indiscretions. The govern- 
ment, to obviate these grave inconveniences, provided the prison of 
Saint Lazare for the accommodation of the inscribed prostitutes, leav- 
ing the hospital du Midi for the other women. 

It is necessary to come down to 1810 in order to find a dispensary 
erected in Paris, with a strong medical staff, for the purpose of visiting 
the prostitutes. In the beginning, they were given the choice of being 
treated at home or in the hospital. The majority took the first alterna- 
tive, but soon the necessity of giving up the house treatment was made 
plain. The medicines were not taken, and those affected with dis- 
eases did not abstain from the exercise of their calling. 

Parent-DuChatelet gave interesting statistical tables of venereal 
diseases among the prostitutes of Paris, aggregating a period of twenty 
years. They show that the proportion of venereal diseases in pros- 
titutes varies widely in the different years. In 1828 six out of one 
hundred prostitutes were diseased, and in 1832 barely three per cent, 
suffered from venereal diseases. 

DuChatelet himself candidly admits that he can trace no law, and 
inclines to the belief that the variation in the number of diseased 
women is wholly due to chance. 



486 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The regulation of prostitution in Paris at present is so interesting 
that it deserves to be briefly described. The total number of prostitutes 
in Paris at the beginning of 1800 was estimated at 25,000 or 30,000, 
of which the city of Paris furnished nearly one-third, the remainder 
coming from the departments, more from the north than from the 
south. The vast majority of these prostitutes were the children of 
operatives and mechanics, and the fathers of one-third of them are 
unable to sign their names. 

The houses of prostitution in Paris are under the surveillance of 
the police. These houses cannot be near the principal streets, must 
not be near a church or a public school. The owner of the house 
must give his consent before the house can be used for a brothel. 
The interior of the house is also watched by the police. It must have 
one room for each girl, it is not allowable for two girls to live in the 
same room, and much less sleep in the same bed. Each room must 
be amply provided with utensils, soap and water for ablution. No 
back entrance or side doors are allowed, nor can a house have dark 
passages or concealed places. No trade or traffic is permitted. 

To open a house of prostitution in Paris requires the authorization 
of the police. Men are not permitted to run houses of this kind. The 
woman who intends to open a house of prostitution must make a 
written application to the prefect of police. She will never receive 
authorization if she has been condemned for crime or for misdemeanor, 
or if her name appears in the police books as a woman requiring super- 
vision. In general those women who have been prostitutes themselves 
are preferred, because they understand the business, and they can only 
aspire to the most demoralizing position, such as a brothel keeper. 
They must be of sober habits, and of a certain force of character to be 
able to command a house of prostitutes. Furthermore, they must 
have some money to guarantee against immediate failure, and must 
own the furniture of the house. 

When the applicant has fulfilled all these conditions, she receives 
a pass book, wherein is specified the number of girls she can keep, and 
she must enter the name of every prostitute she receives as a boarder 
or as a transient lodger, her age, date of entry into the house, date of 
inspection by the physician, and the date of her departure. In the 
book the housekeeper is reminded that she must under heavy penalty 
inscribe on the police rolls every girl she receives, within twenty-four 
hours of her arrival. 

The girls who enter upon the debasing career of the prostitute 
are inscribed as such in the department of the prefecture of police 
called the Bureau des Moeurs. Prostitutes are inscribed either : 






THE REGULATION OF PROSTITUTION 487 

1. On their own request. 

2. On the requisition of the mistress of the house. 

3. On the report of the inspector of prostitutes. 

The girl who, under these circumstances, is taken before the 
Bureau, has to answer a list of twelve questions concerning herself, her 
family, her past life, and the reason for which she wants to be inscribed. 
If she is from some place outside of Paris, the prefect will write to the 
Mayor of the town, informing him that a girl of such a name from his 
town has made such a petition, and requests that he see her parents or 
relatives, and notify them of her wretched resolution. If the family 
declines to interfere, then the girl is duly inscribed on the register. 
At the same time she signs a document where she states, " that, being 
duly acquainted with the sanitary regulations established by the pre- 
fecture for public women, she declares that she will submit to them, 
will allow herself to be visited periodically by the physicians of the 
dispensary, and will conform in all respects to the rules in force." 

Although in some instances the girl may give a false place of 
birth, yet at the present time it very rarely happens, because they 
consider the police as an omniscient machine, which cannot be de- 
ceived. 

In case a girl is brought to the bureau by an inspector as giving 
herself up to clandestine prostitution, she is only admonished and is 
soon released. Only after the third or fourth offense the girl is in- 
scribed on the registers. If the girl has relations or friends in Paris, 
they are sent for and notified. A girl is inscribed only when she is 
evidently lost, but if she shows signs of contrition and shame, she 
is sent home by the police. When the girl is found to be diseased she 
is sent to the hospital. In rare cases it has happened that the girl apply- 
ing for inscription has been found a virgin ; in this case the officials 
have the right to use compulsion to rescue her from infamy. 

The system of inscription of the prostitutes in Paris is so carried 
out that a girl cannot be inscribed unless it is manifest that she will 
carry on the calling of a prostitute whether she be inscribed or not. 
In the same bureau a prostitute who has repented has the right to 
erasure. 

The amendment of prostitutes is encouraged as much as possible. 
The prostitute, however, will not be released from supervision of the 
police and from the visits of the dispensary physicians until there is 
reasonable grounds to believe her repentance and her resolution to be 
sincere and permanent. 

The women, when inscribed as prostitutes, are divided into three 
classes. 



488 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

i. Those who live in licensed houses. 

2. Those who live alone in furnished rooms. 

3. Those who live in rooms they furnish and outwardly bear no 
mark of infamy. 

Before the law there is no difference between the three classes. 
The girl who is inscribed receives her card, with her name and the 
number of the page corresponding to the page of the register. A 
blank column on her card has to be filled by the physician at each 
visit. The dispensary physicians visit the women inmates of the 
brothels in the house where they live; the other prostitutes go to the 
dispensary. Another branch of the dispensary is in the prefecture of 
police, in order to ascertain the sanitary condition of those prostitutes 
who are arrested during the night for drunkenness, or for disorderly 
conduct. 

Every house of prostitution is visited once a week by the dispen- 
sary physicians ; every girl must be present and be inspected. The 
result of the examination is noted in a memorandum by the physician 
and on the pass-book of the house. When a girl is found diseased, 
the mistress of the house is cautioned not to allow the girl to have any 
visitors. In the afternoon of the same day the girl is taken to the dis- 
pensary, where she is again examined, and if found sick, she is sent to 
Saint Lazare to be treated. 

Free prostitutes who live in lodgings, or in rooms furnished by 
themselves, are compelled to visit the dispensary and undergo a visit 
once every two weeks. 

Experience in the French capital has proved that the only means 
of diminishing the spread of venereal diseases is the seclusion of the 
infected prostitutes. 

The prostitutes and the houses of prostitution were obliged to pa> 
a tax, which was used for the support of the dispensary. The product 
of the taxes and fines imposed for transgressions, amounted to some 
75,000 to 90,000 francs per annum. But this system was abolished on 
the ground of immorality. Similar taxes have existed in Lyons, Stras- 
burg and other cities, but the police authorities have taken off these 
taxes and the municipal councils of the city have undertaken to defray 
the expenses of the dispensary. 

The regulation of prostitution in Paris deserves to be specially 
studied. It is the model which has been adopted by every other city or 
state which has intended to regulate prostitution. 

The abolitionists of the control of prostitution have raised strong 
objections to this system. It may be that their objections are well 
founded, but it is undeniable that on reviewing the conditions of pros- 
titution in the different states and cities, it appears, on comparing the 



THE REGULATION OF PROSTITUTION 489 

two conditions, that the regulation of this social evil has always 
brought good results, diminishing the venereal scourge. 

In Spain very little was done to regulate prostitution. Ramon de 
la Segra, 3 in a paper read at the Congress for prevention of syphilis 
and venereal diseases in Brussels, greatly lamented the state of affairs 
in that country, where neither the municipal authorities nor the govern- 
ment had taken any interest in so vital a question of the public health. 
He stated that in Seville, the first-class houses of prostitution retained 
the services of a physician at their own expense, whose office was to 
make examinations of the women. At the last Congress of Brussels, 
the necessity for a surveillance of the prostitution was shown to be 
a fact, and it should be the least vexatious possible, but effective in 
order to attain the great purpose of preventing the spreading of 
syphilis and venereal diseases. This prompted the Commission of the 
Royal Council of Public Health in Madrid 4 to propose a project of 
regulation for prostitution at the Section of Hygiene. The purpose of 
this law is : First, to reduce the cases of contagium which is caused 
by prostitution ; second, to treat the diseased prostitutes ; third, to treat 
and cure men affected with venereal diseases. 

In the individual prophylaxis we have already shown the neces- 
sity of making the treatment as accessible as possible for infected men, 
and this will result in a powerful means for diminishing the contagium. 
The male element, which is so active in the spreading of the disease, 
is yet considered as irresponsible, and can only be checked indirectly 
by treating those infected and by teaching and cautioning the young 
men as to the dangers of venereal diseases. 

It has been recognized that the most effective means of diminish- 
ing the diffusion of syphilis is in an intervention of the municipal 
authorities in the hygiene of prostitution. For this purpose medical 
inspection has been established in Spain, which is exercised to inspect 
the sanitary condition of the public women, and they must be compelled 
by law to obey the rules of hygiene. The medical inspector in visiting 
the inmates of a public house has to sign the individual card of each 
girl. When he finds that a woman is affected with any disease, he will 
write on the card the diagnosis, and will order that the woman be 
immediately taken to the hospital. When the woman is infected with 
syphilis she is compelled to remain in the hospital as long as she has 
symptoms of a condition capable of conveying infection. 

Azua finds it a necessity to establish in the hospitals, small apart- 
ments in pay wards or separate rooms to accommodate women who are 
able to pay for their treatment, while they are compelled to remain in 

3 " Ramon de la Segra." Compt. Rend. Bruxelles, T. i, 1901. 
4 Azua, J. " Reglamentacion Sanitaria." 1905. 



490 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

isolation. In this way the clandestine prostitution would be dimin- 
ished, as those who practice it would not have a horror of being taken 
to the hospital together with prostitutes of the lower class. 

For the regulation of prostitution the strong hand of the police 
is necessary in order to enforce the rules, otherwise the whole system 
will be a farce. A police system should be established in every city 
of 10,000 inhabitants, where there is a Board of Health, in order to 
inspect the sanitary condition of the prostitutes and compel them to 
undergo a regular treatment. The same police inspection should be 
made in all industrial and mineral districts, and also where there are 
military barracks, in order to protect their health from venereal 
infection. 

The physicians in charge of this service must be selected from 
men well versed in handling venereal diseases, in dermatology* and 
syphilology. They must be able to make microscopical examinations, 
and bacteriological cultures to such an extent as to be able to ascertain 
the diagnosis of the disease. 

Every district in the country should have a dispensary for the 
inspection of the prostitutes. The medical office in the dispensary 
should be opened every day except Sunday, but the prostitutes should 
be compelled to undergo the sanitary inspection twice per week. 

In the dispensaries there should be given instructions to the 
prostitutes as to how to recognize some diseases in order to protect 
themselves, and to the men instructions on the prophylaxis of venereal 
diseases. 

Punishment by fine or detention is established for the women 
who refuse to undergo the sanitary inspection, and the raiding of 
the house if the housekeeper allows women to remain without recogni- 
tion of the police officer. 

There are rules to be observed by the police inspectors, and also 
regulations for obtaining the necessary funds, which must be taken 
from the Commission of the Board of Health of the different cities. 

In a country where no surveillance of prostitution was exercised 
it has been found to be a dire necessity. 

In England it seems that prostitution does not exist : the town 
laws regulating prostitution were abolished in 1883, an ^ since then 
prostitution has been left to the common law. and no control is 
exercised. The opinion is that in every community there is some 
prostitution, which is in relation with the habits and education of the 
place, and remains constant so far as the conditions of the place are 
not changed. But in the large cities the search for lust exists under 
all conditions and contributes to the maintenance of prostitution. 
Procuresses are trying to give good service to their patrons, and are 



THE REGULATION OF PROSTITUTION 491 

exerting their hellish ingenuity to find sources of amusement and 
gratification. They go around in the country, to the railroad depots, 
hunting for poor girls to whom they offer friendship and support. 
Sanger relates instances where the procuress has gone to the Sunday 
school in order to approach and decoy female children. The London 
Society for the Protection of Young Females has recorded instances 
of children of eleven years of age entrapped by procuresses into 
houses of prostitution. 

A constant trade in prostitution is carried on between London 
and Hamburg, London and Paris, and London and the country. In 
some cases prostitutes of Paris have been hired for this purpose for 
London, but in the greatest number of cases women have been 
decoyed on the pretence of a legitimate engagement. 

The number of brothels, houses of prostitution and assignation 
houses in London have been variously estimated, and they are found 
in every district. Poverty, poor wages for female work, and over- 
crowded dwellings are the most common causes which lead to 
prostitution. 

The policy of the English law is to compel the woman to pro- 
tect herself, yet unfortunately the scale of human justice is not evenly 
maintained. Legal actions for seduction are very unpopular. It is 
difficult to prove the case, and they usually result in the acquittal of 
the male delinquent. 

The spreading of venereal diseases in Great Britain, and especially 
in London, was found a menace to public health. On February 21 , 
1867, Chas. Drysdale and Tilbury Fox persuaded the members of 
the Harveian Society to establish a permanent committee to study 
this important hygienic question with special reference to the problem 
of prostitution. 

The committee began to study the venereal diseases in the army, 
which is considered the thermometer of the sanitary condition of the 
population. 

In 185 1 the English Army in garrison in the United Kingdom, 
in a total of 44,611 men, gave 8032 cases of venereal infection; an 
average of 180 infected in each 1000 soldiers. 

In 1862 the English Army had over 318 infected in each 1000 

men. At the same time in the French Army 5 with the prophylactic 

rules on prostitution, there were 113 in each 1000 who were infected 

with venereal diseases ; while in Belgium, where the prophylactic 

measures are even stricter, the infected soldiers numbered 72 in 

each 1000. 

5 Crocq et Rollet. " Prophylaxie International des Maladies Ven. Ann. 
Derm, et Syph." 1869. 



492 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

This large number of cases of venereal diseases in the English 
Army prompted on June II, i866 ? an act for the better prevention 
of contagious diseases at certain naval and military stations, which 
had in view the prevention of venereal diseases in the army and 
navy. The law had effect in Portsmouth, Plymouth, Woolwich, Col- 
chester, Sheerness, Aldershot, Windsor, Chatham, Sorncliffe, the Cur- 
ragh, Cork, and Queenstown, all military and naval stations. Under 
this act for prevention of contagious diseases the police of those 
cities had power to take the women known to pursue the calling of 
the prostitute, to a dispensary for medical examination. If they were 
found infected with any venereal or syphilitic disease, they were 
compelled to enter a hospital of the government and remain there 
until recovery was effected. 

The prophylaxis of venereal diseases applied only to the military 
and marine posts, could not bring much benefit unless it was extended 
to the entire population. In fact, referring to the number of venereal 
diseases in Great Britain, and especially in London, there is a great 
deal of conjecture, on account of the great number of hospitals, dis- 
pensaries and clinics, from which it is difficult to obtain positive data. 
Sanger 6 referred to the service of the out-patients in St. Bartholo- 
mew's Hospital under the direction of Lloyd and Vormald, assistant 
surgeons, which has given in a total of 5327 general patients, 2513 
venereal cases. 

From the work of Commenge 7 there can be obtained a good 
idea of the value of the control of prostitution. He gives accurate 
statistical tables which show that in 1875 the French army gave the 
highest number of venereal patients ; amounting to 74.9 in 1000. In 
the same year in the English Army the venereal patients were 1394 
per 1000. The largest number of infected soldiers in the English 
army was in 1885 with 274.4 per 1000, while in the same year in the 
French army the proportion of infected soldiers was 52.1 per 1000. 

For the five years, 1888, 1889, 1890, 1891 and 1892, the soldiers 
of the English army entered the hospitals for venereal diseases in the 
proportion of 224.5 P er 1000, 212. 1 per 1000, 212.4 per 1000, 197.4 
per rooo, 201.2 per 1000. In the same years the French army had 
venereal patients in the number of 46.7 per 1000, 45.8 per 1000, 43.S 
per 1000. 43.7 per 1000, 44 per 1000. In reference to syphilis alone, 
the highest number of infected soldiers in the French army, which 
was in 1875. reached 11.3 per 1000, and in the same year in the 
English army the syphilitic soldiers were 28.8 per 1000. In 1887 in 

6 Sanger. L. c, p. 357. 

7 Commenge, O. " Les maladies veneriennes sans les armees Anglaise, 
Franchise et Rnsse." Paris, 1895. 



THE REGULATION OF PROSTITUTION 493 

the English army syphilitic soldiers reached the proportion of 42.6 
per 1000. In the same year in the French army the proportion of 
syphilitics was 8.9 per 1000, which is only one-fifth of the English 
rate. 

The following statistical table is taken from Commenge to show 
the difference in the proportion of syphilitic soldiers in the two armies. 

French army English army Year 

9.3 per cent. 40.3 per cent. 1888 

9.1 " 35.7 " 1889 

9.1 37.3 " 1890 
8.9 " 32.2 " 1891 

9.2 33.8 " 1892 

A report to the Minister of War showed that in 1892 of the 
effective force of 196,336 soldiers, 52,155 had been sent to the hospitals 
with venereal diseases, more than one-fourth. 

This caused Commenge to write, " La liberte de la prostitution 
amene ches nos voisins des resultats qui ne peuvent pas nous 
surprendre et qui ne doivent pas nous faire regretter les restrictions 
apportees dans notre pays, a cet empoisonement general." 

The great increase in venereal diseases in Great Britain has been 
attributed to the abolition of the Acts of Contagious Diseases. In 
fact in 1 87 1, before the abolition of the Acts, soldiers had been re- 
ceived into the hospitals for secondary syphilis in the proportion of 
21.2 per 1000, while after the abolition the proportion increased to 
33.35 and even 37 per 1000. Officers of the army in India stated that 
nearly half of the soldiers were affected with syphilis. 

In the period 1874 to 1879 under the strict regulation of prosti- 
tution in the military hospitals, there was found an average of 9.53 
per 1000 of soldiers suffering with venereal diseases. 

After the obligatory inspection of the women was suppressed 
the average of venereal diseases has increased to 17.46 per 1000. The 
daily average of soldiers laid up in the hospitals for venereal diseases 
is 4191, which forms four large battalions. 

After these considerations there is no doubt that free prostitution 
increases considerably the spreading of venereal diseases. Commenge 
after studying carefully the statistics of each army corps of the French 
army, shows that clandestine prostitution has great influence on the 
increase of the venereal diseases in the different army corps. He 
refers to Longuet, who remarked that the different army corps con- 
stantly show the number of venereal diseases in nearly identical 
proportion. Those corps of the army most affected are those of the 



494 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

Southern part of France, of Algeria and of Tunis and the 3d army 
corps of the military government of Paris. In 1890 the whole French 
army showed a proportion of venereal diseases of 43.8 per 1000, the 
third corps of the army had 84 per 1000 of soldiers in the hospitals for 
venereal affections. The nth army corps, which was stationed in 
the northern provinces, had only 26.3 per 1000 of diseased soldiers. 

The difference in the proportion of the venereal diseases is to 
be found, according to Commenge, in the facilities which the different 
places of garrison offer to the soldiers. In Algeria and in Paris 
clandestine prostitution is exceedingly common, and so the number 
of infected soldiers is much larger. In manufacturing cities, where 
the young girls are often early debauched, there the number of 
soldiers infected is increased. The ascending progression of the 
venereal diseases is in proportion to the laxity of morality and to the 
facility of the clandestine prostitution. 

In the report of the Surgeon-General of the United States Army 
to the Secretary of War, June, 1900, he shows that in Cuba and Porto 
Rico in the years 1898 and 1899 venereal diseases amongst our troops 
have been indeed excessive, so much so as to cause anxiety to our 
medical officers. Syphilis in Porto Rico had reached 28.38 per cent, 
among the regulars and 50.00 per cent, among the volunteers. In the 
provinces of Santa Clara, Cuba, venereal, diseases had developed at the 
rate of 176.28 per 1000 amongst regulars and 115.69 amongst the 
volunteers. The colored troops were more prevalently affected, reach- 
ing 195.92 per 1000, against 127.35 m the United States. 

Major F. J. Ives, Surgeon United States Volunteers, chief sur- 
geon of the department, was prompted to institute measures of re- 
pression, subjecting the soldiers to a weekly sanitary inspection, and 
those whom he found diseased, were deprived of the privilege of the 
canteen and of the passes from the garrison until cured. In those 
places prostitution was free from all control. 

In Italy the surveillance of prostitution, which had been estab- 
lished under Cavour's ministry as a system of regulation modelled on 
the French plan, was abrogated by Crispi in 1888. The cause was 
that the Section of hygiene at the Congress of Geneva in September 
1887 branded as immoral every system of police des mocurs and all 
regulation of prostitution on the following ground : 

" The obligatory sanitary inspection of the women is revolting 
to human nature and it can reach only a limited number of prostitutes ; 
this inspection cannot discover constitutional syphilis and conse- 
quently gives a false confidence in the women visited." 

As a consequence of these pathetic representations of the aboli- 
tionists, all laws controlling prostitution were repealed, leaving prosti- 



THE REGULATION OF PROSTITUTION 495 

tution free, without registration and without sanitary surveillance. 
The prostitutes, when diseased, could have been treated in any place 
they wanted, by anyone, and in any way. 

In a question of so great importance it is always interesting to 
learn from the experience of others. Free prostitution lasted three 
years and after this period they were compelled to return to the same 
rules, and on October 27, 1891, a new regulation of prostitution was 
enacted and enforced. The results of those three years in Italy are 
entirely identical with those observed in England and in Russia. 
Tarnowski s made a trip to Italy through all the principal cities for 
the purpose of ascertaining the results of the abolition of the control 
of prostitution in the spread of the venereal diseases. In the military 
hospitals, soldiers were laid up with venereal diseases to the fearful 
extent of 62 per cent. All the officers expressed the desire for the 
re-enactment of the laws controlling prostitution. In the civil hos- 
pitals, patients affected with venereal diseases had rapidly increased, 
and in the Ospedale Maggiore of Milan, from 5916 venereal patients, 
in the year 1887-88, the number had increased to 7570 in 1888-89. 

In the Maternity of Milan he found syphilis increased among 
the pregnant women from 1.28 per cent, to 4.27 per cent. In the 
foundling: house of the same city children affected with hereditary 
lues in 1887-88, numbered 23 ; in 1888-89 tnev numbered 49, while 
in 1889-90 they had increased to 98. 

In the hospitals there was found an increased number of" un- 
married women suffering with aggravated cases of venereal and 
syphilitic diseases. In Palermo the rate of diseased women admitted 
to the hospital, which had been on an average of 150 per day, had 
increased by 12 and a great many were suffering with venereal 
affections. 

In the sanitary inspections of the houses of prostitution, when 
under the police surveillance, it was found that 30 per cent, were 
affected with transmittable diseases, but after three years of free 
prostitution the number of diseased prostitutes had risen to 75 per 
cent. These 75 per cent, of prostitutes, affected with gonorrhea, 
chancres, syphilis and every kind of pathological filth, had been left 
free to continue in their callings ; they have spread diseases to hun- 
dreds of young men, with all the consequent results. 

These disastrous consequences in Italy are also perceptible in all 
large cities. They are largely due to those philanthropists who preach 
liberty and morality while holding that sanitary inspection, instead of 
diminishing, increases the chances of spreading venereal diseases. 

8 Tarnowski, B. " Erfahrungen des Abolitionismus in der Prostitution 
Frage in Italien." Ref. Monatsheft. f. prakt. Derm., 1892. 



496 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

The Crispi abolition law, which had been accepted with great 
enthusiasm by the abolitionists, and by many physicians in Italy, 
after three years of free prostitution caused a true reaction in presence 
of the terrible results. 

At the Twelfth International Congress- of Medicine held in 
Moscow in 1897, Serebriakoff 9 stated that the spreading of venereal 
diseases in Moscow was mostly due to the increase of clandestine 
prostitution practiced by women, the majority of whom escaped all 
surveillance. The number of women affected with syphilis, admitted 
into the municipal hospital, is about 50 per cent. Those affected with 
syphilis in the secondary stage form fully one-third of the total. 

Behrend, of Berlin, at the same meeting, expressed frankly his 
opinion that it is the duty of every physician, in spite of the protests 
of women's associations, to demand a strict regulation of prostitution. 
Indeed, women who give themselves to a life of shame, who make a 
trade of their body for the sake of gain and for making their living, 
must be subjected to a sanitary visit from a recognized specialist. 
When the prostitute is found affected with venereal diseases, she 
should be treated in hospitals and not in clinics. They must be 
detained until cure is effected, or at least until there is no more 
danger of spreading infection. In the hospitals, the prostitutes, on 
account of their vicious habits, have to be separated from the other 
patients. 

"All measures proposed by the " abolitionists " show on their part 
dense ignorance of the real condition of the contagiosity of these 
diseases and especially of syphilis. The sanitary inspection is only 
instituted for the purpose of checking venereal diseases and syphilis 
amongst debauched people of both sexes, and so prevent the possible 
spreading of these diseases amongst innocent people, and infecting 
families and even the entire communities. 

On this ground of public hygiene the British Federation is at 
great fault in asserting that the state has no right to interfere in the 
matter of prostitution, because the danger is not in reference to the 
public health, but only to the individual. They claim that the man 
who visits prostitutes willingly and knowingly exposes himself to all 
dangers of infection. But as Sormani remarked, if syphilitic con- 
tagium does not spread through the air at a distance, yet it may so 
insidiously spread that in some cases many members of a family of 
the purest moral habits have, without their knowledge as to the manner, 
been infected with syphilis. It is one of the saddest infections which 
is transmitted to the offspring, which never occurs in other contagious 

9 Ref. Journal of Cutaneous and Genito-urinary Diseases, December, 1897, 
P- 573- 



THE REGULATION OF PROSTITUTION 497 

diseases. The child born with congenital syphilis, is often made the 
center of infection and is capable of spreading the disease amongst 
healthy people. Cases of epidemics of syphilis have been reported by 
Riccordi, 10 when in 1863, a foundling babe tainted with congenital 
syphilis was adopted into a family who did not know its condition ; 
this child was the cause of communicating the disease to 23 persons. 
In the same year in Uboldo, another foundling babe infected her wet 
nurse, and the disease spread among 18 persons. 

In the province of Abruzzi in Capistrello, an epidemic of syphilis 
developed, which was not recognized by the local physicians, and in 
five years infected nearly 300 persons. The epidemic was found to 
have started from an infected babe taken from the foundling house 
and adopted into a family. The well-known work of Dr. L. Duncan 
Bulkley, " Syphilis in the Innocent," which has already been quoted, 
gives a sufficient idea of the large number of victims of the syphilitic 
infection, where there has been no fault of the infected. 

In 1861 the Bavarian Parliament voted a law, which imposed 
severe penalties on all women who practiced prostitution. All houses 
of prostitution w r ere closed, and all sanitary inspection was discon- 
tinued. It was found in the city of Munich that in the preceding 
years the number of venereal patients in the hospital of the city were 
on an average 1006 per annum. In the five years following the 
abolition of surveillance, the number of venereal patients increased 
to 1500, and in 1866 reached the number of 1835. 

Commenge, referring to the abolition of surveillance of prostitution 
in Bavaria, found a great difference in the proportion of venereal 
patients of both sexes. In the time of surveillance, male venereal 
patients had been received in the hospitals in proportion of 203 for 
100 female venereal patients. At the time when the inspection was 
discontinued the number of male venereal patients reached 335 for 
100 female patients. This shows that diseased women do not apply 
willingly to the hospital for treatment, but they remain outside to 
spread infection as long as they can, without any thought of the sad 
consequences resulting from their criminal carelessness. 

Neisser, 11 after his philosophical considerations on prostitution 
and crime, on the difference between a fallen woman and a prostitute, 
reaches the conclusion that prostitution is an unavoidable evil, which 
cannot be fought, but must be tolerated, consequently with some 
restrictions. When the prostitute is infected with venereal diseases 
she is a danger, and therefore the prostitutes must be subjected to 
sanitary inspection so as to be able to isolate them in the beginning 

10 Riccordi, quoted by Commenge, 1. c, p. 37. 

11 Neisser, A. " Rapport sur la Phophylaxie Publique," Brussels, 1902. 



498 THE MEDICO-LEGAL AND SOCIOL9GICAL ASPECTS 

of the disease. The elimination of diseased women is useful for them 
and for others. It is useful for them because the disease taken in the 
very beginning yields much more easily to treatment, and useful for 
others who would without any doubt be infected. 

In a recent work Blaschko, 12 with well selected statistics from 
Denmark, where physicians are compelled to report all cases of 
venereal diseases under their treatment, without mentioning the name 
of the patients, in a period of twenty years from 1876 to 1895, was 
able to demonstrate a decrease in the percentage of these diseases. 
In Copenhagen in the decennium 1876- 1885 gonorrhea is given as 
5645; ulcus molle as 1450; syphilis as 1203. In the decennium 1886- 
1895 gonorrhea is found as 4618; ulcus molle as 842 ; syphilis as 1254, 
showing a small increase for syphilis only. In the same paper he 
refers to statistics taken in Prussia in 1900, where it is shown that 
on April 30 of that year in the whole kingdom 41,000 persons were 
suffering with sexual diseases, of which 11,000 were infected with 
recent cases of syphilis. In Berlin there were recorded 11,600 venereal 
patients of whom 3000 had fresh cases of syphilis and were under 
medical treatment. From the same statistics it is shown that in Berlin 
for every 10,000 inhabitants, 142 are suffering venereal diseases. 
These statistics, however, give only a very faint idea of the real number 
of infected persons, because of the physicians who were requested to 
send the number of their venereal cases, only one-half answered the 
request. Furthermore many of these cases go to be treated by drug- 
gists and by quacks, who surely were not asked for any information 
on the subject. This shows that the number given in the statistics 
must be considered about one-third of the real number of venereal 
patients in Berlin. Blaschko thinks that every year the number of 
diseased persons is 200 in each 1000 young men between twenty and 
thirty years of age, of which five-sixths are suffering with gonorrhea, 
and one-sixth or 34 are affected with fresh cases of syphilis. 

In reference to the spreading of the venereal diseases in the 
different classes of society, we find it interesting in the same statistical 
tables that in Berlin, soldiers are affected at the rate of four per 
cent., working people at nine per cent., merchants at sixteen per cent., 
students at twenty-five per cent., clandestine prostitution at thirty 
per cent. 

The large number of infected students has indicated the necessity 
of instituting societies for the prevention of sexual diseases among 
students. The object of the society is to show to the young students 
the danger of infection which is connected with each sexual relation 

12 Blaschko, A. " Der Einfluss der Syphilis auf die Lebensdauer." Int. 
Kongr. f. Versiches Mediz., 1906. 



THE REGULATION OF PROSTITUTION 499 

and the sad and disastrous consequences of these diseases on the 
individual health. Besides this, it is the duty of the society to 
inculcate on the students who have the misfortune of being infected, 
the necessity of applying for a good medical treatment. In the same 
way the society teaches them not to be misled by false shame, to 
hide the disease and go to consult quacks or follow advice of so-called 
friends, but to immediately place themselves under the care of a 
reputed physician, and obtain the recovery without risking tedious 
and dangerous complications. Scholtz, 13 who has charge of the sick 
students in Breslau, remarks that he finds among them a great ig- 
norance of the possibility of infection through sexual relations, and 
of the consequences, and so they readily and thoughtlessly expose 
themselves to the venereal peril. It seems that from the teachings 
of these societies there have been obtained some good results, as 
shown by the clinical histories. Formerly, thirty-five per cent, of the 
students were affected with gonorrhea and went to the dispensary 
only once for a free consultation, and now seventeen per cent, of the 
students affected with gonorrhea are following their treatment to the 
end. This shows that the students at present have a much better 
idea of the venereal peril, are more careful, and nobody attempts to 
apply a treatment of his own. The efforts made by Professor 
Neisser, who has given some public lectures to all students on the 
venereal peril, are producing good effects in diminishing the venereal 
scourge. On the other hand, the regulation of prostitution by the 
police with a sanitary inspection made by men who have made vener- 
ology and dermatology their special studies is a necessity for checking 
the spreading of these contagious diseases. 

Indeed, under the English regulation system at home and 
abroad British soldiers and sailors were required to denounce the 
women who had infected them. The women were examined and 
most of them were declared free from disease. 

Miss Blanche Leppington, 14 quoting the official statistics for 
Hong Kong, gave an instance where 139 women were denounced, of 
whom 102 were found clinically free from disease, and another 
instance where of 103 denounced women, in 101 there could not be 
found any venereal infection. At that time, 1886-1888, these medical 
reports were accepted as proof that the women had been falsely 
charged. To-day a simple medical inspection will have no value unless 
it is corroborated by microscopical examination. For this reason not 

13 Scholtz, W. " Ueber die Bekampfung- der Geschlechtskrankheiten unter 
der Studenten." Munch, med. Wochensch. No. 5, 1901. 

14 Leppington, Miss B. " Responsabilite civile et penale." 77 Confer. 
Intern. Brussels, 1902. 



5 oo THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

every physician can fill the position of medical inspector, unless he is 

well trained in this branch of medical knowledge. 

Kromayer 15 referred to a statistical table from Blaschko 16 to 

show the frequency of syphilis in the different cities. The table shows 

also the difference between the prostitutes in the brothels and the 

free prostitutes. 

In the 
brothels Free 

Paris, 1878-1887 12.0 7.0 

Brussels, 1887-1889 25.0 9.0 

Petersburg, 1890 33.5 12.0 

Antwerp, 1882-1884 51.3 y.y 

Hammer 17 referred to the condition of prostitution in Stuttgart 
when a mild system of regulation was enacted in 1894. At that time 
among 1725 prostitutes arrested by the police, 146 were affected with 
secondary syphilis, an average of 8.5 per cent. Gratifying results from 
the regulation were shown by the number of venereal patients amongst 
the soldiers of the garrison. In 1893 before the surveillance, gonor- 
rhea was 16.7 per cent., ulcus molle 7.09 per cent., syphilis 6.07 per 
cent. In 1896, two years after the regulation of prostitution, the 
number of soldiers affected were, gonorrhea 10.3 per cent., ulcus 
molle 3.0 per cent., syphilis 4.7 per cent., showing a considerable 
diminution. 

Kromayer in reviewing the statistics of many states and cities, 
compares those where prostitution is under surveillance and those 
where prostitution is free, showing the difference. He referred to 
the city of Colmar in Alsace, where in 1881 by order of the Mayor 
the houses of prostitution were closed and all surveillance abolished. 
Taking the statistics from the diseased soldiers of the garrison, it 
was found that in the first year there was a diminution of venereal 
patients, but this diminution was only ephemeral, because in the fol- 
lowing years venereal diseases increased more than double. In the 
beginning, this closing of the public houses brought a diminution 
because the soldiers were somewhat afraid and restrained themselves, 
but soon a clandestine system of prostitution developed, which caused 
in 1890, 128 disabled soldiers to be in the hospital with venereal in- 
fection, while in 188 1 only 64 soldiers had been diseased. The 
proportion of diseased soldiers in a small garrison in Colmar with 
free prostitution was 57 per cent., while the whole Alsatian army 

15 Kromayer, E. " Zur Austilgung der Syphilis," Berlin, 1898, p. 14. 

16 Blaschko. " Syphilis und Prostitution vom Standpnnkt der offentlichen 
Gesundheitspflege," Berlin, 1893. 

17 Hammer. " Ueber Prostitution und venerische Erkrankungen in Stutt- 
gart." Arch. f. Derm. u. Syph, 1897. Bd. 38, p. 253. 



THE REGULATION OF PROSTITUTION 



50I 



corps had given only 26 per cent, and in Strasburg, the capital of 
the province, the proportion was 29 per cent. 

On the other hand, it seems that a too strict and vexatious system 
of surveillance of prostitution has the opposite effect ; instead of dimin- 
ishing it has increased the number of venereal patients. In Breslau, 
when a strict control of prostitution was enacted, at first the number 
of venereal soldiers of the garrison greatly diminished, so much so, 
that from 37 per cent, in 1886 it fell to 20 per cent, in 1889, but in 
the following years the number of infected soldiers began to increase 
and in 1892 the prostitution had again reached 27 per cent, in com- 
parison with 28 per cent, of the year 1887 before the regulation. 

The too strict rules, which had been enforced in 1887, took many 
prostitutes out of their regular houses and as a consequence clandes- 
tine prostitution took place, producing nearly the same results as did 
the closing of all the houses in Colmar. 

These results, however, are not to be considered from the point 
of view of the abolitionists, because the strict control of prostitution 
has always the object of removing infected women from the position 
of being able to spread infection, and this is always a public benefit. 
If on account of the frequent relapses in the gonorrheal infection the 
control of prostitution does not give such good prevention results, 
yet in syphilis it is greatly beneficial. By means of the sanitary in-' 
spection, syphilitic infections are easily recognized, and the infected 
women are soon placed in hospitals and treated until cure is effected. 
Moreover by a prophylactic treatment the relapses of syphilitic symp- 
toms are easily prevented. Indeed, the greatest beneficial result of 
the surveillance of prostitution is mostly found in checking the spread- 
ing of syphilis. 

For this reason Kromayer earnestly censures those states, where, 
through the indolence of the legislatures, so terrible a disease as 
syphilis is left alone to spread among the masses without an effort to 
combat its progress. This check can be obtained, not by the private 
efforts of the physicians, but by all the restrictions and compulsory 
laws of the government, and of the municipalities. 

In the United States, and only recently, a system of surveillance 
of prostitution has been adopted in a few cities at different times and 
with variable results. To the efforts of Dyer 18 is due the scanty 
information which could be obtained from forty-four cities, in refer- 
ence to the condition of prostitution. For all 44, excluding 
Philadelphia, in a population of 7,684,938, there was found a total 
of prostitutes of 69,440, giving one prostitute to every no inhabitants. 

18 Dyer, Isadore. "The Municipal Control of Prostitution in the United 
States." New Orleans Medical and Surgical Journal, 1899. 



502 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

From many cities no information could be obtained for the reason 
that as prostitution was forbidden by state and city laws no records 
are kept. From the replies obtained by Dyer it is clear that in eleven 
cities prostitution was free, and in thirty-four cities prostitution was 
under surveillance. In two cities prostitution was restricted to a cer- 
tain part of the city, in twelve it was prohibited, and in nine it was 
ignored. 

In reference to the existing laws concerning prostitution it was 
found, that of 68 cities, 20 had no laws ; 12 had State laws ; 32 had 
prohibitory laws ; 9 had a license or enacted fine ; 3 confined the loca- 
tion of houses and of prostitutes to certain districts ; one city rang 
a curfew bell at 9 P. M. requiring prostitutes to be indoors ; 2 cities 
occasionally raid houses and two others occasionally arrested prosti- 
tutes for the effect produced ; two cities have laws to suppress ; one 
to restrict ; one city had no legal recognition of prostitution and one 
stated that this condition is tacitly tolerated. 

In going over the work of Dyer it clearly appears that the health 
officers or the mayors of the cities had only very little idea of this 
occult evil, prostitution, and of its consequences in spreading infection. 
Very little could be learned concerning the examination of prosti- 
tutes, no answer could be obtained in reference to the microscopical 
examinations of the secretions for gonococci. Xo definite idea could 
be obtained in reference to the age of prostitutes, to the prostitution 
among minors, to the class of society from which they came, to the 
general influences driving them to prostitution. 

In reference to a law requiring medical examination of prosti- 
tutes, it can be said that no such legislation or regulation exists in the 
United States. In San Francisco, Cal., San Antonio, Texas, and St. 
Louis. Mo., they have tried to force such regulation, but not effectu- 
allv. When prostitutes were found to be diseased, are they compelled 
to remain in a hospital or are they treated at home? To this question 
replv was that no compulsory treatment was instituted in the United 
States ; they stay where they wish and are usually treated domiciliarily. 

In reference to the danger of spreading venereal diseases and 
especially syphilis, it seems to be the general opinion that clandestine 
prostitution is the most dangerous. 

From all the meager data that Dyer was able to collect, the im- 
pression was that there is a woeful lack of municipal supervision, 
knowledge and control of prostitution and of venereal diseases in the 
United States. The general public is not only indifferent, but scorn 
the question of prostitution, which is left to the police department as 
a vice, crime and nuisance. Their ignorance of this evil has indeed 
contributed to the grade of outlawry shown by prostitution. 



THE REGULATION OF PROSTITUTION 503 

Prohibition of prostitution does not stop the evil, but makes 
things worse, increasing the number of clandestine prostitutes. The 
efforts of religious fanatics have succeeded in nothing but spreading 
the evil and in increasing the number of street walkers and soliciting 
prostitutes who were formerly housed. A clear example was found 
in 1891 in Pittsburg and in 1892 in New York, where the closing of 
the public houses had no other effect than spreading clandestine 
prostitution to every corner of the city. 

In the report of the Committee of Seven on the prophylaxis of 
venereal diseases in the city of New York, the chairman, Dr. Prince 
A. Morrow, 19 greatly lamented the lack of statistics concerning the 
prevalence of venereal diseases in that city. That the existence of 
this class of diseases had always been ignored by the sanitary authori- 
ties, and in consequence the amount of venereal morbidity was only 
conjectural. From the answers obtained from one-third of the 678 
physicians asked to reply to a circular, it was found that in New York 
at that time, in 1901, were 23,196 venereal cases, of which 15,969 
were cases of gonorrhea and 7200 cases of syphilis. This number 
does not include the cases of chancroid, which is estimated at from 
9 to 35 per cent, of the total venereal morbidity. In the same way in 
this number there was not included the large number of the sequelae 
of gonorrhea, as pelvic complications, strictures and all the troubles 
which have a venereal origin. 

Morrow justly remarked that the 23,196 cases were given only 
by one-third of the physicians, and assuming that an equal amount 
of diseases had occurred in the practice of those who gave no report, 
the total of cases of gonorrhea and syphilis would reach 162,372 for 
that year in the city of New York. This calculation cannot even be 
considered approximative, when we think that from 25 to 50 per cent, 
of venereal diseases are treated by quacks, and by druggists, or by 
friends. 

In the small part of statistics collected, 12,956 cases of gonorrhea 
there were only 194 1 women of whom 724 were suffering with pelvic 
complications. Among children there were 265 affected with gonor- 
rheal ophthalmia; 218 with vulvovaginitis; 5 with urethritis. In the 
group of syphilis 1657 cases were in women and 61 in children in 
acquired form, showing infection in the family. Four hundred and 
sixty-eight children were tainted with hereditary syphilis. 

In reference to the origin of the infection, the committee could 
not obtain definite information, for the reason that in this country 
there does not exist any regular system of registration such as there 
is in Europe. From the few data it resulted that 8053 cases of infec- 

19 Morrow, P. A. The Medical News, Dec. 21, 1901. 



504 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

tion were attributed to public and 3915 to clandestine prostitutes, which 
is entirely in opposition with the observation of other countries. 

Nine hundred and eighty-eight cases of infection were reported 
as from husband to wife. From the report of dispensaries and of 
charitable institutions in Manhattan, there could be obtained informa- 
tion from 37. The aggregate number of venereal diseases was 
14,649 cases of gonorrhea, and 7607 cases of syphilis, giving a total 
of 22,256. In the hospitals it was found difficult to get information 
in reference to venereal diseases, which are usually recorded under 
different names so as to mask their origin. They found in the eye 
hospitals 136 cases recorded as purulent ophthalmia, in all of which 
the microscopic examination had revealed the presence of the gono- 
cocci. In the same institutions 38 cases of interstitial keratitis, un- 
doubtedly of syphilitic origin, were not recorded as such. 

In the annual report of the general hospital there were registered 
371 cases of salpingitis; 1762 of endometritis; 335 of pyosalpinx; 45 
of salpingo-ovaritis ; 48 of vulvovaginal abscess; 169 of vaginitis; 651 
of stricture ; 173 of gonorrheal rheumatism. From all the data which 
the members of the committee could gather, it resulted that in the 
hospitals and dispensaries of New York city there had been treated 
41,439 cases of venereal diseases and of sequelae or consequences of 
the same origin. 

Yet in presence of so enormous a spreading of venereal diseases, 
the hospitals still refuse to admit patients at the time when they can 
be cured and also be prevented from infecting others. They are 
admitted into the hospitals when they are suffering from some grave 
consequences of the disease, but then it receives a different name and 
does not hurt the feelings of the susceptible directors of the institution. 

Sanger estimated that 59^ per cent, of all inmates admitted into 
any public institution, city hospital, almshouse, workhouse, peniten- 
tiary, etc., were suffering with venereal diseases. From all the dif- 
ferent sources of information Sanger concluded that in 1892, 100,000 
persons in New York were suffering from syphilis out of a population 
of 1,800,000. At the present time the population of New York has 
reached 3,500,000, and calculated at the same rate of the increase in 
the venereal affections, it can be assumed with Morrow that 200,000 
of all the population are infected with syphilis, and according to the 
calculation of Sanger 365,000 men are suffering with venereal diseases 
in Greater New York. 

In the presence of so serious a state of affairs, we see the health 
officers busy with the precautions to be taken for all contagious 
diseases and entirely ignoring the venereal diseases which belong in 
the category of the most contagious, and are of the most insidious. 



THE REGULATION OF PROSTITUTION 505 

A system of surveillance does not acknowledge or legalize the vice, 
but is in conformity with the Prussian laws, which formally state that 
vice is tolerated but not permitted. 

Indeed, as Morrow refers to the different views of the medical 
profession, 340 physicians have recommended, as a radical measure 
to prevent the spreading of the venereal contagium, the regulation of 
prostitution. The system of regulation in France, which is not too 
strict nor vexatious, has been copied by nearly all countries or munici- 
palities which have established rules of this kind. It represents an 
association or a combination of the efforts of the administration of 
the authorities and of the medical profession in order to render 
prostitution less dangerous to the public health, eliminating the source 
of contagium in women who are engaged in it. A regular medical 
visitation of all prostitutes is the essential part of any regulation. 
This sanitary inspection subjects, of necessity, the prostitute to an 
effective supervision by the police. The medical inspection is also 
advocated by the brothel-keepers, so that at the first symptoms the 
disease may be checked. 

All the arguments to show the horrors of the venereal scourge 
have not been capable of removing the prejudice. The good people 
prefer to ignore the matter, they would rather let the river rise and 
devastate the properties than build dykes and regulate the current. 
So far State or municipal legislation for the control and regulation 
of prostitution has remained but a recommendation of the committee. 

In 1894 a system of protection was inaugurated in the city of 
Cincinnati, through the efforts of an eminent jurist, Hon. John A. 
Caldwell, who was at the time mayor of the city. He was greatly 
affected by a pathetic letter written by a mother, who complained that 
her only boy, a lad of sixteen, had been so badly diseased that he was 
laid up in bed. The mayor requested the lady to have a conference 
with him in order to ascertain the party who had infected her son. A 
few generalities were given pointing to a young woman riding a 
bicycle, etc. The mayor detailed a special detective, who ascertaining 
the identity of the woman, took her to the hospital, where she was 
found suffering with secondary syphilis, mucous patches of the lips 
and of the tongue, and gonorrhea. The detective worked on the case, 
and found that nine other boys had been infected by the same woman, 
and to her was traced the cause of the suicide of one of the most 
prominent business men. Continuous complaints of the same kind 
prompted the mayor to have a consultation with the chief of police, 
then Col. Phil. Deitsch, to see if any steps could be taken to provide 
for some restriction of prostitution. 

He found in the law, Sec. 112 Revised Statutes for Ohio, that 



506 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

when a woman in a house of disreputable character, or an assignation 
house, is found affected with disease, she must be sent to the hospital 
and detained there until cured, and the expenses of the treatment art 
to be a lien on the house. This law afforded a good ground to 
institute some regulation of prostitution. 

The chief of police then detailed two detectives to look after the 
houses of prostitution and all places of a suspicious character. The 
dive-keepers were obliged to report to the police the number and the 
names of the girls, who were inmates of their houses, and also report 
the changes, those who had come to, or had left the house. When the 
dive-keeper knew of a girl being diseased, he was compelled to report 
the case and the girl was sent to the hospital. If a case of a diseased 
girl was not reported, a sanitary inspection was ordered by the police, 
and when found diseased, the house was raided and the inmates were 
taken to the station house, and those affected with venereal diseases 
were sent to the hospital. 

In order that the city should not be charged with the expenses, 
Mayor Caldwell ordered that for the sanitary inspection the brothel- 
keepers could choose their own physician, who left them the required 
certificate of good health. The women were visited once in a while by 
a physician appointed by the mayor, and when girls were found 
infected with syphilis or venereal diseases the house was raided, the 
diseased women were committed to the hospital, and the physician 
who had left the certificate was notified that he could not serve any 
more in that capacity, because his certificate would be rejected. 

In the Cincinnati Hospital where the O Ward was purposely 
established for venereal patients, amongst prostitutes we find the fol- 
lowing data. In 1890, 117; in 1891, 164; in 1892, 131; in 1893, 142; 
in 1894, 224; in 1895, 220; in 1896, 182; in 1897, 194; in 1898, 144; 
in 1899, 149; in 1900, 248; in 1901, 529; in 1902, 324; in 1903, 369; 
in 1904, 914; in 1905, 688; in the year 1906, 203. 

Sanitary inspection with the regulation of prostitution was 
ordered and effected in 1894 and the number of diseased prostitutes 
which in 1890 to 1893 had oscillated between 117 and 142 rose to 
224, showing an increase to nearly double. 

In 1897 by order of Mayor Gustave Tafel, the sanitary inspec- 
tion was discontinued, and diseased prostitutes could no more be 
detained in the hospital during their treatment. The physician in 
charge was compelled to obey the orders of the prostitutes who came 
of their own accord, when they were a mass of decay, and as soon as 
they were somewhat better they asked for their dismissal. The venereal 
ward for women was converted into a kind of boarding house ; they 
had a right to habeas corpus, and were free to go whenever they 



THE REGULATION OF PROSTITUTION 



507 



liked. This condition of affairs caused the number of diseased prosti- 
tutes, which was 194 in 1897, after the abolition of surveillance in 
1898 to drop to 144 and in 1899 to 149. 

In 1900, under the administration of Mayor Julius Fleischmann, 
the regulation of prostitution was reinstated and the administration 
was entrusted to the hands of the Board of Health. Dr. Clark W. 
Davis deserved a great deal of credit for setting the machinery in 
working order. He first selected his own physicians on whom to rely 
for their skill in venereal and cutaneous diseases, and on their good 
character, so as to avoid the many irregularities and the many 
mistakes, which were committed by physicians not very familiar with 
this branch of medical science. The prostitutes and all sporting 
women were all secretly registered in the private office of the health 
officer, their name was known only to him and to the officers of the 
department. Together with their names, they recorded their address. 
When registered, they were compelled to be examined by one of the 
examining physicians, and received a certificate of good health from 
the Health Office. When they were found suffering with syphilis or 
with a venereal or contagious disease, they were sent directly to the 
hospital. 

The houses of prostitution were inspected by a special officer, 
to ascertain the number of the inmates and see that the report of the 
house-keeper was truthful. When it came to the knowledge of the 
inspector that in the house there were girls not registered or not 
accounted for, the house was raided. It was the duty of the house- 
keeper to report every new girl, and the latter had to be registered 
and examined by the Health Department before she was permitted to 
remain there. 

The health officer, before permitting a girl to be registered, tried 
to explain to her the gravity of the step she was going to take. 
Usually all those women asking for registration were found so well 
advanced in their calling, that the admonition never had a good effect. 
Yet once in a while girls had been sent back to their homes at the 
expense of the Health Department. They were good honest girls 
decoyed by procuresses and detained as prisoners by the brothel- 
keepers. 

The prostitutes were examined once a week; the inspecting physi- 
cian made an examination of the skin to see whether any eruption was 
present either due to syphilis or any other contagious cause such as 
scabies, etc. The mucous membrane of the mouth, tongue and throat 
was to be carefully inspected, to ascertain the presence of syphilitic 
mucous patches. The genital organs were then carefully inspected 
for any eruption, moist papules, or venereal warts. Next the urethra 



508 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

and the excretory ducts of the Bartholinian glands were inspected, and 
when any secretion was seen, it was placed on a glass slide for micro- 
scopical examination. The speculum was then introduced and any 
mucus found in the cul-de-sac of the vagina, or oozing from the cervix, 
was likewise taken, spread on a glass slide for microscopical examina- 
tion. The slides were labeled and on each one was the name of the 
girl from whom it was taken. The bacteriologist of the city made the 
examination, and when gonococci were found present, the house- 
keeper was notified not to let the girl have any visitors, and in the 
afternoon or on the following morning she was taken to the hospital. 

In the examination when girls were found affected with pediculi 
pubis they were also taken to the hospital to be sure that they were 
free from that filth. 

At the hospital there often apply for treatment women affected 
with deeply ulcerated gummata, with syphilitic periostitis, etc., but 
this kind of women usually do not come from the brothels ; they apply 
for relief of their sufferings of their own accord. 

The examining physician at every weekly sanitary visit left with 
the examined girl a new certificate, on which he wrote, well — or, 
affected with syphilis, or — affected with gonorrhea. He wrote the 
same on the stub, which was sent to the Health Office to give account 
of the result of the examination. 

From the registers of the Health Office from January, 1903, to 
January, 1904, it is found that 625 women had registered as public 
prostitutes. They had been visited weekly during the year and 340 
of them had been found diseased, and had been sent to the hospital 
for treatment. Some of them requested to leave the city, or they had 
been claimed by their relatives and had been sent home. 

In one week 482 girls were visited by the inspecting physicians, 
and only 19 were found diseased and were sent to the hospital. This 
number gave an average of 4 per cent, as diseased prostitutes. 

This system of protection in a short time gave wonderful results. 
The number of diseased women diminished from 529 in 1901 to 324 
in 1902. When the women know that they have to be examined, they 
keep themselves clean and try to avoid infection, as they know that, 
when they are found diseased, it means they must be taken to the 
hospital. Moreover, when they are infected, the disease is treated in 
the very beginning and in a short time it yields to the remedies and 
the woman leaves the hospital cured, or at least in condition not to be 
a menace to public health. 

In 1906 the change of administration has brought men to power 
who do not believe in the regulation of prostitution and they have 
abolished all the system, and all inspection has been discontinued. 



1904 


1 


905 


] 


906 


MALE FEMALE 


MALE 


FEMALE 


MALE 


FEMALE 


14 15 


14 


I 


17 


2 


75 192 


52 


139 


65 


78 


10 14 


4 


5 


12 


4 


5 12 


9 


— 


6 


3 


76 713 


77 


544 


72 


135 


3 2 


2 


1 


4 


2 


30 9 


43 


4 


53 


4 


2 8 


2 


16 


1 


— 


25 16 


22 


8 


18 


9 


18 5 


6 


5 


15 


3 



THE REGULATION OF PROSTITUTION 509 

The venereal ward for females was soon deserted and from 688 dis- 
eased prostitutes in 1905, their number dropped to 203 in 1906. The 
diminution in the number of diseased prostitutes has been usually 
followed by the increase of patients in the male venereal ward. 

Only a few women had applied for treatment to the venereal 
ward of their own accord, and were in such miserable condition that 
they were utterly disabled. The following statistical figures were 
taken from the records of the venereal wards of the City Hospital in 
order to t>e able to maintain the truthfulness of the assertion. 

CINCINNATI HOSPITAL 



Syphilis Initial lesion 

Secondaria 

Tertiaria 

Congenital 
Gonorrhea with complications 76 

Ophthalmia 
Chancroid with bubo 
Venereal Warts 

Scabies 
Phthiriasis 

Total 258 986 231 723 263 240 

It is clearly shown that in 1904 there were treated in the City 
Hospital 1244 venereal patients; in 1905, 954, and in 1906, when the 
surveillance of prostitution was abolished, 503. The results would 
at the first glance appear as if the venereal diseases under the time 
of regulation had increased and under free prostitution diminished. 
This, however, is entirely misleading, because venereal diseases are 
concealed and it is necessary to find them out and take them to the 
hospital for treatment and isolation. When prostitution is left free, 
the few cases of gonorrhea in females which come to the hospital are 
all grave cases with complications extending to the endometrium, 
tubes and ovaries. In most of the cases surgical intervention is neces- 
sary and the patients remain a long time for treatment. Under regu- 
lation the cases of gonorrhea that come in at the very beginning, are 
limited to the cervix or to the vaginal cul-de-sac, and in an average 
of three or four weeks gonococci are not found and the girls are dis- 
charged well. 

Cases of syphilis at secondary period when the contagium is 
more easily transferred, at the time of free prostitution came to the 
hospital at an average of 28 to 32 ; when the regulation of prosti- 
tution was enforced, prostitutes with secondary symptoms were taken 
to the hospital at the rate of from 95 to 193 ; when prostitution was 



5io THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 

left undisturbed, prostitutes with grave secondary syphilis applied 
willingly to the hospital because they could not continue in their 
calling, and they could not stand on their feet. The number of syphi- 
litic prostitutes dropped again to 37, 53 and 78, not because their 
number had diminished, but only because they were not inspected, and 
they were not compelled to remain in the hospital. This shows that 
more than 50 per cent, of syphilitic prostitutes at the height of contagi- 
osity are left free to inoculate syphilis in every way, even accidentally. 
A comparative table taken from the clinics of the Medical College 
of Ohio of the years 1905 (last year of regulation) and 1906, when 
all rules were abolished, was furnished by our clinical assistant, Dr. 
E. B. Tauber. 





1905 




1 


906 




MALE FEMALE 


MALE 


FEMALE 


Syphilis 


42 


24 


58 


35 


Gonorrhea 


190 


22 


347 


1 10 


Chancroids 


9 


2 


17 


3 


Scabies 


16 


13 


22 


23 


Phthiriasis 


17 


IS 


29 


22 



Total ... 274 76 473 193 

It is clearly shown that under free prostitution the number of 
male patients suffering with venereal diseases has doubled. The num- 
ber of gonorrheal patients is so large in the clinics, because they are 
not accepted in the hospital unless affected with complications which 
render them disabled. 

The increase in the number of cases of scabies in our city is so ap- 
parent that nearly every physician has noted the large number affected 
by this disease. Entire families in the city have been found suffering 
with scabies, which, although, not a venereal disease must, nevertheless, 
be laid at the door of prostitution. Many prostitutes suffering with 
scabies have the disease for a long time before they decide to be 
treated, and they distribute their filth without any care. 

The surveillance of prostitutes is also of great advantage for the 
scope of the police ; among prostitutes some are guilty of other crimes 
or misdemeanors, and the knowledge of their whereabouts is a 
necessity. 

Many prostitutes go from one city to another, and when they 
know that in a city there is no control of prostitution, they flock there 
in order to be free from inspection. It is therefore of great importance 
for the health officers of different cities where regulation is maintained, 
to have an understanding, that when a prostitute affected with syphilis 
at the condylomatous period leaves a city to go to another, to notify 
the Health Department of her arrival in the other city. Often pros- 
titutes suffering with secondary syphilis have been released from the 



THE REGULATION OF PROSTITUTION 511 

hospital because they requested to be sent home to their relatives. This 
ought never to be allowed as long as they have symptoms which are 
dangerous as a source of infection, and they ought to be detained in 
the hospital. 

Another danger to the community at large is shown in our statis- 
tics., where of 2768 women affected with venereal diseases, 875 were 
domestics. In our city we have always found that when prostitution 
is free some of these women styling themselves domestics follow the 
calling of the harlot, and when so diseased that they could not remain 
in the houses of prostitution, they looked for employment as servant 
girls in a family. 

There is no better protection for the public than the hospitalization 
of the diseased prostitutes, and of any woman infected with venereal 
diseases leading an immoral life. A woman of this kind as long as she 
can receive a visitor will not decline his company. For this reason 
the treatment must be carried on in the hospital, and the woman must 
be secluded. 

In the hospital the venereal department for females ought to be 
furnished with sewing and working rooms, where diseased prostitutes 
can find occupation in the seclusion during their treatment. In these 
working rooms, Christian and philanthropic women will find a good 
opportunity to improve the condition of these poor misled creatures, 
and to try to elevate their morals, so as to change their lives and bring 
them back from vice to virtue. Philanthropists will find ample oppor- 
tunity to establish houses of patronage and rescue institutions, where a 
prostitute who intends rehabilitation may be sheltered, taught and 
helped to find honest occupation in order to earn her living. 

The conclusion reached at the second International Conference 
in Brussels for the prevention of syphilis and venereal diseases will 
always remain from the standpoint of public prophylaxis a maxim, 
"Prostitution must be regulated by law," and the application of this 
law must be left in the hands of the Health Department of the com- 
munities and of the municipalities. 

Medical inspection of the prostitutes is a necessity, an inspection 
which has to be made by experts in that branch of medicine. All 
persons who, being infected with venereal diseases, continue to have 
sexual intercourse are committing a crime and should be punished 
by law. 

Prostitution is not to be considered as a crime, and should only be, 
punished as such in the cases in which society is offended by the 
demoralizing conduct of the prostitute. 

In order to avoid the spreading of syphilis accidentally, the health 
officers of the communities should regulate the barber shops, and 



512 



THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 



insist that barbers should sterilize their instruments before using them 
on the next customer. 

The dentists have to be taught the dangers of communicating 
syphilis with their instruments, and the necessity, after the instruments 
have been used, of placing them in a sterilizer with boiling water. 

The public in general has to be taught of the danger of infection 
by drinking from cups used by everybody in the factories or in the 
public places, and of the necessity of rinsing them before putting them 
to the mouth. 

The government, the administration and the physicians have to 
join hands to combat all the possible causes capable of spreading 
syphilis as a contagious and insidious ailment, one which tends to 
degenerate the individual, ruin the welfare of man, the family and 
society. Experience has shown that a well-directed system of sur- 
veillance is advantageous and useful to the community in lessening 
this evil. 



INDEX 



INDEX 



Adenopathy, primary, 36 
Albuminuria, syphilitic, 81 
Alcohol, effect on syphilis, 140 
Alimentary canal, syphilis of, 65 
Alopecia, syphilitic, 42, 52 
Aneurisms in syphilis, 74, 75 
Animal inoculation, 9 
Antitoxins of syphilis, 259 
Apes, inoculation of, 9 
Aphasia in syphilis, no 
Aponeuroses, syphilis of, 104 
Army — venereal diseases in, 491 
Arteritis, 74, 100 
Arthritis 

differential diagnosis, 101 

gonorrheal, ioi, 161 
' syphilitic 100 

Bacteriology of syphilis, i 
Blood 

in acquired syphilis, 39, 185 

in hereditary syphilis, 295 
Blood vessels in syphilis, 72 
Bones 

differential diagnosis, 99 

pain, character of, 96 

syphilis of, 90 
Brain 

acquired syphilis, 105, 117 

hereditary syphilis, 288 
Bronchi, syphilis of, 69 
Bubo 

chancroidal, 16, 36 

syphilitic, 16, 36 
Bursae, syphilis of, 103 

Carcinoma with syphilis, 58, 65, 168 

Cerebral syphilis, 105, 117 

Chancre 

eroded, 29 

extra-genital, 22 

Hunterian, 15, 28 

induration, 30 

initial papule, 31 

location, 22, S3 

"mixed," 31 

multiplicity of, 33 

chancre parchemine, 15, 28 

pathological anatomy, 28 

post-initial, 17 

symptoms, 34 

treatment of, 179 

ulcerated, 30 



Chancroid, 31 
Cheeks, syphilis of, 60 
Circumcision, 225 
Colles' Law, 254 
Congenital syphilis, 264 

constitutional treatment of, 27s 

diseases associated with, 270 

general treatment of, 271 

idiocy in, 289 

prophylaxis, 275 

symptoms, 266 
Conjunctiva, syphilis of, 129 
Cornea, syphilis of, 129 
Cortex, syphilis of, 107 
Coryza in syphilitic children 

treatment, 272 
Courts, juvenile, 465 
Crime, syphilis predisposing cause, 392 
Cutis variegata 

Dactylitis, syphilitic, 98 
Damages in syphilis, 324 
Dangers from syphilis, 144 
Decadence of population and syphilis, 

37° 

Degeneracy in relation to syphilis, 352 

physical signs of, 366 
Diabetes in syphilis, 84 
Divorce and syphilis, 319 
Dystrophies, 311 

in hereditary syphilis, 307 

parasyphilitic, 153 

statistics, 307 

Ear, syphilis of, 131 
Edema indurativum, 34 
Education of young men, 224 
Elephantiasis, 60 
Endarteritis, 74, JJ, 364 
Epididymis, syphilis of, 85 
Epilepsy in syphilis, 109, 288, 345 
Erysipelas and syphilis, 163 
Ethics with syphilitic patients, 326 
Eye, syphilis of, 127 
Eyebrow, syphilis of, 127 
Eyelid, syphilis of, 128 

Fasciae, syphilis of, 104 
Fetus, syphilitic, 248, 264 
Fever, syphilitic, 19 

malarial type, 21, 40 
Fragilitis ossium, 93 
Fungus testiculi syphiliticus, 87 



515 



5i ( 



INDEX 



Genito-urinary tract, FEMALE — SYPH- 
ILIS OF, 89 

Genito-urinary tract, male — syphilis of, 

Glossitis cicatrisans, 65 
Glycosuria in syphilis, 84 
Gonorrhea and syphilis, 138, 158, 161 

Hair, syphilitic affections of the, 

42, 52 
Headache in syphilis, 106, 107 
Hemiplegia in syphilis, 108, in, 288, 

289 
Hereditary syphilis, 284 

blood in, 295 

bones in, 292 

brain in, 288 

deafness, 287 

epilepsy in, 288, 345 

interstitial keratitis in, 286 

latency of, 297 

lymphatic glands in, 294 

mortality in, 279 

prophylaxis in, 275 

skin in, 290 

testes in, 293 

tongue in, 292 

treatment, 312 
Heart _ 

acquired syphilis of, "J2 

hereditary syphilis of, 312 
History of syphilis, 370 
Hot Springs, Ark., 212 
Hutchinson's teeth, 286 

Idiocy, relation to syphilis, 289 
Immunity, syphilitic, 254 
Impotence, 87 
Infection in syphilis 

direct, 235 

germinative, 238 

mixed, 138, 157 

modes of, 22 

pathology of, 13 

post-initial, 39 
Insanity in syphilis, 117, 122 
Introduction of syphilis into Europe, 

370 
Iodides, 213 
Iodipin, 217 
Iodism, 214 
Iris, syphilis of, 131 

Joints 

differential diagnosis, 101 
gonorrhea, 101 
syphilis, 100 

Keratitis, 130, 286 
Kidneys, syphilis of, 80 



Larynx, syphilis of, 68 
Leprosy and syphilis, 168 
Leucoderma, 43, 48 
Leucoplakia, 64 

Life insurance and syphilis, 425 
Ligaments, syphilis of, 104 
Lips, syphilis of, 60, 63 
Liver, syphilis of, 80 
Locomotor ataxia, 121, 124 
Lungs, syphilis of, 70 
Lymph glands 

in hereditary syphilis, 294 

in primary syphilis, 36 

diagnosis of syphilitic and chan- 
croidal, 36 
Lymphangitis, syphilitic, 35 

Malaria and Syphilis, 167 
Malignancy of syphilis, 136, 139 
Marriage and syphilis, 317, 338 
Medical secret, 329 
Meninges, syphilis of, 106, 113 
Mercury, absorption through skin, 198 

physiological action of^ 205 

poisoning, 211 

stomatitis, 208 
Metasyphilis, 123 
Microcephalus, 366 
Monstrosities, 310 
Mucous patches, 62, 63 
Muscles, syphilis of, 101 

Nails, changes in, 53 

in tissue surrounding, 53 
Nephritis in syphilis, 80 
Nervous system, syphilis of, 105 
Neuritis in syphilis, 108, no, 121, 131 
Nose, syphilis of, 66 

Olfactory nerve, syphilis of, 133 
Optic neuritis, 108, no, 121, 131 
Orchitis, syphilitic, 86 

differential diagnosis of tuberculosis. 
88 
Osteitis, condensing, 92 

formative, 91 

rarefying, 91 
Ovaries, syphilis of, 89 

Palate, syphilis of, 60, 63 

Pancreas, syphilis of, 80 

Paralysis in syphilis, 108, in, 114, 121, 

123, 126 
Paranoia, 388 
Paraphimosis, 226 
Parasyphilis, 152, 309 

characters of, 153 

treatment in, 155 
Paresis, 118, 121 
Penis, elephantiasis, 60 

syphilitic eruptions of, 84 



INDEX 



517 



Periostitis, syphilitic, 90, 93 

Phagedenic ulcers, 290 

Pharnyx, syphilis of, 61, 63 

Phimosis, 225 

Phlebitis, syphilitic, 78 

Pigmentation, 48 

Placenta, infection through, 246 

pathology of, 246, 264 
Plaques des fumeurs, 64 
Polyuria in syphilis, 84 
Populations, decadence of in syphilis, 

370 
Prevention and coercion, 463 
Profeta's law, 256 
Prophylaxis, circumcision in, 225 

individual, 223 

in regard to prostitution, 439 
Prostitution, causes of, 452 

of minors, 448 

legal penalties for, 444 

proxenetism and procuresses, 456 

public prophylaxis, 439 

regulation of, 480 
in Paris, 486 
in Spain, 489 

sanitary consequences, 459 
Protozoon-like bodies of Schtiller, 8 
Proxenetism and procuresses, 456 
Pseudo-tabes, 115 
Public health and syphilis, 412 
Purpura syphilitica of newborn, 75, 269 

Respiratory tract, syphilis of, 66 

Saddle nose^ 67 
Schools, industrial, 473 
Sclerotic, syphilis of, 130 
Sexual perversion and syphilis, 405 
Skin (see syphilodermata), 41 

absorption of mercury, 198 

congenital syphilis, 266 

hereditary syphilis, 290 

late syphilis of, 54 
Smokers' patches, 64 
Spermatic cord, syphilis of, 88 
Spinal cord, syphilis of, 112 
Spirochaeta pallida, 10 

Giemsa's stain for smears, 11 

Levaditi's silver method for tissue, 11 

location of, 12 

morphology of, 11 

Schaudinn's discovery of, 10 
Spirochaeta refringens, 11 
Spleen, syphilis of, 79 
Stages of syphilis, 136 
Stains 

Giemsa's for spirochaetae, 11 

Levaditi's silver stain, 11 
Statistics, mortality in congenital syph- 
ilis, 279 

mortality caused by syphilis, 146, 416 



Statistics 
of offspring of syphilitics, 302 
of syphilis in prostitutes, 459 
pregnancies in syphilis, 150, 302 
registration of prostitutes, 449 
venereal diseases in armies, 491, 493, 

494 

venereal diseases in hospital of Cin- 
cinnati, 419, 420, 421 
Sterility from syphilis, 251 
Stomatitis mercuralis, 64, 208 
Syphilis, adenopathy, 36 

alcohol in, 140 

and marriage, 317 

animal inoculation, 9 

antitoxins in, 259 

associated with other diseases, 142 

bacteriology of, 1 

blood in, 39, 185, 295 

brain in, 105, 117, 288 

carcinoma associated with, 58 

congenital, 264 

constitutional, 19, 21, 34, 38 

coryza in syphilitic children, 272 

dactylitis, 98 

differential diagnosis, 59 

edema indurativum, 34 

fever in, 19 

gonorrhea and, 161 

hair in, 42, 52 

hereditary, 284 

hereditaria retarda, 284 

Hutchinson's teeth, 286 

immunity in, 254 

individual dangers from, 143 

influence of, on other diseases, 158 

influence of other diseases on, 142 

locomotor ataxia, 121 

of male genito-urinary tract, 84 

malignancy, causes of, 136, 139 

medico-legal aspect of, 317 

mixed infection, 138, 158 

modes of infection, 22 

mortality from, 146 

nails in, 53 

of alimentary canal, 65 

of aponeuroses, 104 

of blood vessels, 72 

of bones, 90 

of brain, 105, 117 

of bronchi, 69 

of bursas, 103 

of cheeks, 60 

of conjunctiva, 129 

of cornea, 129 

of cortex, 107 

of ear, 131 

of epididymis, 85 

of eye, 127 

of eyebrow, 127 

of fasciae, 104 



5i8 



INDEX 



Svphilis of female genito-urinary tract, 

89 

of heart, 72 

of iris, 131 

of joints, 100 

of kidneys, 80 

of larynx, 68 

of ligaments, 104 

of lips, 60, 63 

of liver, 80 

of lungs, 70 

of meninges, 106, 113 

of muscles, 101 

of nervous system, 105 

of nose, 66 

of olfactory nerve, 133 

of optic nerve, 108 

of ovaries, 89 

of palate, 60, 63 

of pancreas, 80 

of penis, 85 

of pharynx, 61, 63 

of respiratory tract, 66 

of sclerotic, 130 

of skin, 41, 54 

of spinal cord, 112 

of spleen, 79 

of tendons, 103 

of testicle, 86 

of third generation, 299 

of tongue, 60, 63, 64 

of tonsils, 60, 63 

of trachea, 69 

of urethra, 84 

of uterus, 90 

of vagina, 89 

of vas deferens, 88 

of vulva, 89 

protozoon bodies of Schiiller, 8 

pseudo-tabes syphilitica, 115 

sociological aspect of, 317 

spirochasta pallida, 10 

stages of, 136 

statistic data of, 125 

symptoms second incubation, 40 

tobacco in, 141 

toxins in, 259 

treatment of, 171 

tuberculosis with, 59 
Syphilis binaria, 301 
Syphilis hereditaria tarda, 284 
Syphilodermata, annular, 42 

ecthymatous, 50 

framboesiform, 50 

gummatous, 54, 56 

gyrate, 42 

lenticular papular, 43 

macular, 41 

miliary papular, 43 

moist papules, 46 

palmar, 43, 45 



Syphilodermata, papular, 42 
papulo-crustosa, 49 
papulo-pustulosa, 49 
pigmentary, 48 
plantar, 43, 45 _ 

pustular syphilide, differential diag- 
nosis of, 51 
rupial, 51 
ulcerative, 55 
vegetating, 46 
vesicular, 44 

Taste in syphilis, 133 
Tendons, syphilis of, 103 
Testicle : acquired syphilis, 86 

differential diagnosis, 88 

hereditary syphilis, 293 

hydrocele, 86 

tuberculosis, 88 
Tobacco in Syphilis, 62, 141 
Tongue : acquired syphilis, 60, 63, 64 

hereditary syphilis, 292 
Tonsils, syphilis of, 60, 63 
Touch in sj^philis, 134 
Toxins of syphilis, 259 
Trachea, syphilis of, 69 
Transmission of S3*philis 

by conception, 235 

direct, 229 

from maternal side, 245, 250 

from paternal side, 241 

by tertiary products, 231, 241, 258 
Treatment of syphilis : baths, 212 

external, 177 

fumigation, 202 

injection, 189 

internal, 183 

iodides, 213 

iodipin, 217 

iodism, 214 

inunction, 195 

of congenital syphilis, 271 

time for beginning, 184 
Tuberculosis with syphilis, 58, 140, 165 

lupus of oral cavity, 64 

of vulva, 59 

treatment of, 59 
Typhoid fever and syphilis, 167 

Urethra, syphilis of, 31, 84 
Uterus, syphilis of, 90 

Vagina, syphilis of, 89 

Vas deferens, syphilis of, 88 

Vulva : elephantiasis, 60 

syphilis of, 89 

S}Hphilitic ulceration, 59 

tuberculous ulceration, 59 

Waters of Hot Springs, Ark., 212 



SEP 7 1907 



LIBRARY OF CONGRESS — 

029 827 900 9 



